S. HRG.

107103

INDIAN HEALTH CARE IMPROVEMENT ACT

HEARING
BEFORE THE

COMMITTEE ON INDIAN AFFAIRS

UNITED STATES SENATE
ONE HUNDRED SEVENTH CONGRESS
FIRST SESSION

ON

THE INDIAN HEALTH CARE IMPROVEMENT ACT FOCUSING ON

PERSONNEL ISSUES AND URBAN INDIAN HEALTH CARE PROGRAMS

JULY 31, 2001

WASHINGTON, DC

U.S. GOVERNMENT PRINTING OFFICE

74575 PDF WASHINGTON : 2002

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 COMMITTEE ON INDIAN AFFAIRS
DANIEL K. INOUYE, Hawaii, Chairman
BEN NIGHTHORSE CAMPBELL, Colorado, Vice Chairman
FRANK MURKOWSKI, Alaska KENT CONRAD, North Dakota
JOHN McCAIN, Arizona, HARRY REID, Nevada
PETE V. DOMENICI, New Mexico DANIEL K. AKAKA, Hawaii
CRAIG THOMAS, Wyoming PAUL WELLSTONE, Minnesota
ORRIN G. HATCH, Utah BYRON L. DORGAN, North Dakota
JAMES M. INHOFE, Oklahoma TIM JOHNSON, South Dakota
MARIA CANTWELL, Washington
PATRICIA M. ZELL, Majority Staff Director/Chief Counsel
PAUL MOOREHEAD, Minority Staff Director/Chief Counsel

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 CONTENTS

Page
Statements:
Bird, Michael, president, American Public Health Association, Albuquer-
que, NM ......................................................................................................... 6
Campbell, Hon. Ben Nighthorse, U.S. Senator from Colorado, vice chair-
man, Committee on Indian Affairs .............................................................. 1
Culbertson, Kay, executive director, Denver Indian Health and Family
Services, Inc., Denver, CO ............................................................................ 30
Hall, Robert, president, National Council of Urban Indian Health, Wash-
ington, DC ..................................................................................................... 19
Hill, Barry T., director, Natural Resources and Environment, General
Accounting Office, Washington, DC ............................................................ 5
Hunter, Anthony, health director, American Indian Community House,
New York, NY ............................................................................................... 21
Inouye, Hon. Daniel K., U.S. Senator from Hawaii, chairman, Committee
on Indian Affairs ........................................................................................... 1
Malcolm, Jeffrey, senior evaluator, Natural Resources and Environment,
General Accounting Office, Washington, DC .............................................. 5
Meyers, Carol, executive director, Missoula Indian Center, Missoula, MT . 24
Vanderwagen, William C., acting chief medical officer, Office of the Direc-
tor, Indian Health Service, United States Department of Health and
Human Services, Rockville, MD .................................................................. 2
Waukazoo, Martin, executive director, Native American Health Center,
Oakland, CA .................................................................................................. 26

APPENDIX
Prepared statements:
Bird, Michael (with attachment) ..................................................................... 50
Conrad, Hon. Kent, U.S. Senator from North Dakota .................................. 45
Culbertson, Kay ................................................................................................ 58
Daschle, Hon. Tom, U.S. Senator from South Dakota .................................. 45
Forquera, Ralph, executive director, Seattle Indian Health Board (with
attachments) .................................................................................................. 97
Hall, Robert ....................................................................................................... 75
Hill, Barry T. (with attachments) ................................................................... 65
Hunter, Anthony (with attachments) ............................................................. 87
Meyers, Carol .................................................................................................... 53
Taylor, Jr., Wayne, chairman, Hopi Tribe ...................................................... 61
Valadez, Ramona, executive director, Native Direction, Inc. (with attach-
ments) ............................................................................................................ 139
Vanderwagen, William C. ................................................................................ 48
Waukazoo, Martin ............................................................................................ 56
Additional material submitted for the record:
Magedanz, Tom, staff, South Dakota-Tribal Relations Committee, memo-
randum (with attachments) ......................................................................... 152
Perdue, Karen, commissioner, Department of Health and Social Services,
Alaska ............................................................................................................ 158

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 INDIAN HEALTH CARE IMPROVEMENT ACT

TUESDAY, JULY 31, 2001

U.S. SENATE,
COMMITTEE ON INDIAN AFFAIRS,
Washington, DC.
The committee met, pursuant to notice, at 10:05 a.m. in room
485, Russell Senate Building, Hon. Daniel K. Inouye (chairman of
the committee) presiding.
Present: Senators Inouye, Conrad, and Campbell.
STATEMENT OF HON. DANIEL K. INOUYE, U.S. SENATOR FROM
HAWAII, CHAIRMAN, COMMITTEE ON INDIAN AFFAIRS
The CHAIRMAN. The committee meets this morning to receive tes-
timony on the challenges confronting the Indian Health Service,
privately-administered health care programs, and urban Indian
health care programs with regard to recruiting and retaining
health care professionals today and in the years ahead.
Todays hearing will also address the challenges confronting the
urban Indian health care programs as they address the health care
needs of Indian people residing in urban areasa population which
now represents 60 percent of the total population in Indian coun-
try.
The committee is pleased to welcome the witnesses. We look for-
ward to your testimony.
Before we do, I am pleased to call upon our vice chairman.
STATEMENT OF HON. BEN NIGHTHORSE CAMPBELL, U.S. SEN-
ATOR FROM COLORADO, VICE CHAIRMAN, COMMITTEE ON
INDIAN AFFAIRS
Senator CAMPBELL. Thank you, Mr. Chairman.
In the 106th Congress the committee held four hearings on var-
ious parts of S. 212, and today we will continue with that series
of hearings. This bill would reauthorize the Indian Health Care Im-
provement Act, the core act that authorizes the majority of Indian
health programs.
We have both said many times in the past Mr. Chairman, the
American Indians and Native Alaskans continue to suffer the worst
health status of any group in America. Since 1976 this act has been
a powerful tool in helping tribes and the IHS change the health
status of Native populations for the better. Since the initial pas-
sage of the act, the death rate among the Native population has de-
creased in all categories, and the provision of health services has
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 2

improved overall. I believe S. 212 will put us on the right path of

achieving the goals that we first set out to accomplish in 1976.
Today well discuss an issue of growing concern to me, and thats
the provision of health care for our urban Indian population. Over
one-half of our Indian population lives off-reservation, most of them
in urban areas, and yet funding for the urban programs in the IHS
system is still only 1.14 percent of the entire IHS budget and has
remained stable for the last 3 years, even though the urban Indian
population is growing.
Today well also look at the personnel programs of IHS. One of
the purposes of the Health Care Improvement Act was to increase
the number of Native people who enter this profession. I think the
act has already helped many individuals enter the profession, but
I also think we need to look more closely to see if we are doing all
we can do to attract more Indian people, as well as other dedicated
health professionals, in the Indian Health Services.
I look forward to the hearing, Mr. Chairman. Thank you for call-
ing it.
The CHAIRMAN. I thank you very much.
Our first panel consists of the following: The acting chief medical
officer, Office of the Director, Indian Health Service, Department of
Health and Human Services, Dr. William C. Vanderwagen; the di-
rector of the Natural Resources and Environment, General Ac-
counting Office, Barry T. Hill, and he will be accompanied by Jef-
frey Malcolm, senior evaluator, Natural Resources and Environ-
ment; and the president of the American Public Health Association,
Michael Bird.
I am pleased to call upon Dr. Vanderwagen. Welcome.

STATEMENT OF WILLIAM C. VANDERWAGEN, ACTING CHIEF

MEDICAL OFFICER, OFFICE OF THE DIRECTOR, INDIAN
HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN
SERVICES, ROCKVILLE, MD
Mr. VANDERWAGEN. Thank you, Mr. Chairman, and good morn-
ing to you. It is so good to see you here.
We appreciate greatly the committee taking the time to review
with us the issues of concern to the committee and to Indian people
with regards to Indian health manpower and the needs of urban
Indian people.
I have a prepared statement which I would ask to be entered
into the record.
The CHAIRMAN. Without objection, so ordered.
Dr. VANDERWAGEN. Thank you, sir.
As both you and the vice chairman have noted, sir, the health
status of Indian people still lags well behind that of the general
U.S. population. Diabetes is at least four-fold what it is in the gen-
eral population, alcoholism is seven-fold what it is in the general
population, et cetera.
The Congress has given us what I view to be a very sacred mis-
sion, and that is to elevate the health status of American Indians
and Alaska Natives to the highest possible level and develop the
capacity of Indian communities to manage and direct their own
health care systems.
 3

Today, as we talk about manpower, I think the issue of have we

discharged that responsibility with some success around building
local capacity is what we would like to talk with you about. We be-
lieve there are clear indicators of success.
For example, in the ITU settingthat is, in the Indian Health
Service, tribal, and urban programsand we are a health system
now that encompasses those three facetsFederal, tribal, urban
75 percent of the staff in those organizations are Indian people,
and it is because of the scholarship program, its because of the
CHR program.
I like to believe that the woman who 30 years ago became a CHR
supported her daughter through the scholarship program to become
an RN, and now her daughter is attending medical school, and
weve seen that kind of change in the development of professional
skills and capacities in the Indian communities. We think that is
good public health. It strengthens those communities and their
ability to take care of issues.
Weve also had a variety of other opportunities provided to us in
terms of how we approach recruitment and retention. Today we
have with us here in this audience a number of folks who are work-
ing with Indian Health Service this summer. They are future lead-
ers in Indian health. Some of them are wearing uniforms. They
came to the co-step program. We have two medical students from
the Uniformed Services University here. We have students in the
undergraduate area who are here courtesy of the Washington In-
ternship for Native Students at AU. We have people who are here
because of the externship program that we have available to us
under the Indian health manpower authorities. These are the fu-
ture leaders of Indian health. So we believe there has been success
in developing Indian peoples capacity to manage and deliver their
own health system.
There are still recruitment issues to be addressed. Using the loan
repayment authority provided, we have been able to expand the
number of individuals, professional individuals that we are able to
bring to Indian country to assist us in meeting these health chal-
lenges of diabetes, of alcohol, and other issues. This would include
podiatrists, pharmacists, nurses, dentists, physicians. We continue
to have vacancy rates that exceed the general population. Our phy-
sician-to-population ratio still exceeds 1-to-1,000, compared to, say,
the District, where it is 1-to-250. So we still have recruitment chal-
lenges to address.
We have significant retention challenges, as well. The difficulty
in being isolated, cultural transition, and dealing with a system
that is severely rationed does lead to turnover, and, in fact, those
vacancy rates that I mentioned earlier in some measure are reflec-
tive of those issues.
The average tenure of our staff is less than we would like it to
be. Physicians stay on average 8 years. Nurses stay on average 12
years. Wed like to see them for a whole career. That is a challenge
that we have in front of us yet in manpower recruitment and reten-
tion.
The urban programs are a significant concern to us in the agen-
cy. In the last 5-to-7 years, under the leadership of our director, Dr.
Trujillo, we have taken the approach that I mentioned earlier
 4

that we are the Federal, the tribal, and the urban programs that
are a health system for delivery of health services to Indian people.
As Mr. Campbell noted, significant increases in urban population
are confronting us, in part because cities have now grown to res-
ervation boundaries. Albuquerque can no longer grow north, west,
or south, because they have reached reservation boundaries. And,
in fact, those Indian people who live on those reservations are now
urban Indians in that they live within an SMSA. On the other
hand, the population that was moved in the 1950s and their chil-
dren and grandchildren has expanded significantly, as well. So
there are real issues to address in meeting the health needs of
urban people.
While we talk about health statistics in Indian populations, we
dont have the data we need to fully understand the specific issues
that affect urban Indian people. We have only now, in the last 112
years, established an epidemiology center with a focus on health
needs of urban Indian people. The data needs are large for trying
to understand where the issues are and how we can best address
them, and thats a task that were taking on in consultation with
urban people.
Urban Indians have been included fully in the consultation proc-
ess around budget allocation. They have been included in the budg-
et formulation process. We will continue to include them as active
partners in this health system for Indian people, and we believe
that they are active and viable partners.
I would be remiss if I didnt note that most of those programs,
on average only about one-third of their funding comes through the
Federal sector funded by Indian Health Service. A significant
amount of their funding comes from other Federal programs and
State and county programs, as well. They have been very success-
ful at surviving and expanding their programs. I will give you but
one example.
In Los Angeles County, a 400-square-mile area, the Indian popu-
lation is diffusely scattered throughout that area. The approach
that has been developed is a managed care approach with case
managers, since theres really no focused population of urban peo-
ple, and these case managers work with individual urban people to
identify the best care locations for those people, whether theyre in
the northeast corner of the county or theyre in the southwest cor-
ner of the county, and it has been a very successful program.
Because of unique needs in behavioral health, the State and
county, and particularly the county of Los Angeles, have now
helped that clinic start an active outpatient behavioral health pro-
gram. They just opened it 5 months ago. One-half of the county
commissioners appeared at the opening of this program, and it is
a testimony to the resourcefulness of those Indian people in L.A.
as to the quality of the job that they have been able to do.
There are real challenges, and we appreciate the opportunity to
be here today, and Ill be happy to answer any questions you may
have as the hearing progresses.
Thank you.
The CHAIRMAN. I thank you very much, Doctor.
[Prepared statement of Dr. Vanderwagen appears in appendix.]
The CHAIRMAN. May I now call on Mr. Hill.
 5
STATEMENT OF BARRY T. HILL, DIRECTOR, NATURAL RE-
SOURCES AND ENVIRONMENT, GENERAL ACCOUNTING OF-
FICE, WASHINGTON, DC, ACCOMPANIED BY JEFFERY MAL-
COLM, SENIOR ANALYST
Mr. HILL. Thank you, Mr. Chairman. It is certainly a pleasure
for Mr. Malcolm and me to appear before this committee. Were
here today to discuss the issue of Federal tort claims coverage for
tribal contractors, and my comments this morning will focus spe-
cifically on the FTCA coverage and claims history for tribal self-de-
termination contracts at the Indian Health Service.
If I may, Id like to briefly summarize my prepared statement
and submit the full text of my statement for the record.
The CHAIRMAN. Without objection, so ordered.
Mr. HILL. Last year we issued a report to this committee on the
combined FTCA claims history for tribal self-determination con-
tracts at the Indian Health Service [IHS] and the Bureau of Indian
Affairs [BIA]. That report provides more details about the provi-
sions that extended FTCA coverage to tribal contractors and four
emerging legal issues affecting FTCA coverage for those contrac-
tors.
For my testimony today, weve updated the status of the IHS
claims since our report last year, and the figures I will be present-
ing were current as of July 15, 2001.
Let me start my testimony today by briefly describing the process
for implementing FTCA coverage for tribal self-determination con-
tracts.
We are here today because accidents happen, and when those ac-
cidents are caused by the negligent actions of a tribal employee,
the injured parties may be able to seek compensation from the Fed-
eral Government for their personal injuries. For example, if a pa-
tient receives negligent care at a tribal health facility or there is
an accident involving a tribal ambulance, the injured party may be
able to seek compensation from the Federal Government. Federal
regulations implementing FTCA prescribe the process that Federal
agencies must follow in resolving claims arising from the negligent
or wrongful acts of Federal employees. With the extension of FTCA
coverage to tribal contractors, tribal employees or volunteers under
a self-determination contract are considered Federal employees for
the purpose of FTCA coverage.
According to the FTCA regulation, claims are subject first to the
administrative review and determination by the Federal agency
whose actions gave rise to the claim. These claims must be pre-
sented in writing to the agency within two years, and they must
contain a request for a specific amount of compensation.
At the administrative level, claims arising from IHS programs
are filed with the Department of Health and Human Services
Claims Branch in Rockville, MD. The Claims Branch has been del-
egated authority to resolve claims of $10,000 or less, and the De-
partments Office of General Counsel issues administrative deter-
minations for claims in excess of $10,000.
Due to medical malpractice considerations, medical-related
claims go through a much more rigorous review process than non-
medical claims.
 6

If the claim is not resolved administratively, a lawsuit may be

filed in Federal court where the Department of Justice will defend
it. Administrative and legal settlements may be paid from agency
funds, the U.S. Treasury, or a tribes private liability insurance if
duplicate coverage exists.
The Department of Health and Human Services identified 114
claims involving tribal contractors of IHS programs that were filed
during fiscal years 199799. The total damages claimed were $487
million, with patient care activities accounting for nearly 45 per-
cent of these claims and vehicle accidents accounting for another
35 percent.
These claims involve tribally-contracted programs for 40 contrac-
tors. The Navajo Nation, the largest tribe, had the most claims,
with 14, and 6 other contractors had 5 or more claims during this
3-year period.
The damages claimed ranged from a low of $75 to a high of $100
million, with a median claim amount of $1 million. And, as of July
15, 40 claims had resulted in settlement payments, 18 were ulti-
mately denied, and the final outcome of 56 claims is still pending
either administratively or in litigation. A total of 58 claims or 51
percent have been brought to closure at a cost of $680,000 out of
the $230 million claimed in those cases. The small, simple claims
for minor incidents, such as a fender bender, are generally resolved
quickly, while the large, complex claims may take longer to resolve.
The total settlement figure paid to date amounts to $680,000;
however, this figure will likely increase as the remaining claims
are resolved.
Finally, we found that claims involving tribal contractors are
being processed the same way as claims involving Federal employ-
ees, and that the percentage of tribal claims approved and the
amount awarded are comparable with the resolution of other FTCA
claims at the Department of Health and Human Services.
Mr. Chairman, that concludes my statement. Id be pleased to re-
spond to any questions that you or members may have.
The CHAIRMAN. Thank you very much.
[Prepared statement of Mr. Hill appears in appendix.]
The CHAIRMAN. Now may I call on Mr. Bird.
STATEMENT OF MICHAEL BIRD, PRESIDENT, AMERICAN
PUBLIC HEALTH ASSOCIATION, ALBUQUERQUE, NM
Mr. BIRD. Good morning, Mr. Chairman and members of the
committee. You have my written document which has been submit-
ted to you. Id like now just to go into a narrative description on
my comments.
I am Michael Bird, Santa Domingo and San Juan Pueblo Indian
from New Mexico. I am president of the American Public Health
Association. Im the first American Indian president of the Amer-
ican Public Health Association in 128 years, so if patience is a vir-
tue Indian people must be very virtuous.
Today I am representing the Friends of Indian Health, the coali-
tion of over 40 organizations and individuals. We thank you for the
opportunity to testify today and to comment on health care person-
nel issues that we think should be addressed in the reauthorization
of the Indian Health Care Improvement Act.
 7

Id like to share a quote with you:

The first Americans, the Indians, are the most deprived and most isolated minor-
ity group in our Nation. On virtually every scale of measurementemployment, in-
come, education, and healththe conditions of the Indian people ranks at the bot-
tom.
Mr. Chairman, this quote was made over 30 years ago by then
President Richard M. Nixon. Unfortunately, little has changed
since then, especially in regards to health care for American Indi-
ans and Alaska Natives.
Recently, a member of the Friends of Indian Health sought care
from the Phoenix Indian Medical Center for a 1 oclock doctors ap-
pointment. He left his home at 11 a.m., arriving at noon. He knew
that he needed to arrive 1 hour before his appointment because pa-
tients are seen on a first-come, first-served basis, even those with
scheduled appointments. At this facility, the patient-to-doctor ratio
is overwhelming. Not only does it serve Indian patients within the
Phoenix city limits, but also patients are brought to the Phoenix
Indian Medical Center by vans from adjacent reservations that lack
inpatient services.
Our friend was eventually seen, but also told that his back condi-
tion had worsened and that he would probably need surgery. Be-
cause of a lack of orthopedists at Phoenix Indian Medical Center,
he was unable to schedule consultation until September 27.
The patients checkup took all afternoon. This experience is not
unique. There is disparity in access to care throughout the Indian
health care system. Or another way to view this situation is to
compare the IHS to the Phoenix Veterans Medical Center, which
is within 1 mile from the Phoenix Indian Medical Center. The total
number of outpatient visits at the VA facility was over 8,000, com-
pared to more than 14,000 at the Phoenix Indian Medical Center,
a difference of over 6,000. The VA employs nine psychologists,
while the Phoenix Indian Medical Center employs four. The total
number of behavioral staff at the VA was 75, as compared to 17
at the Phoenix Indian Medical Center.
The Friends of Indian Health believes that by improving access
to treatment and prevention the IHS will make significant strides
in reducing health disparities and mortality rates. This was dem-
onstrated by the placement of a podiatrist with the Winnebago and
Omaha Tribes. During his 4-year tenure, the average annual leg
amputations fell from 16 to 0. Not only did this improve the daily
living and quality of life for the patients and their families, but re-
sulted in a cost savings of over $2 million in surgical expenses.
But the IHS needs to move quickly to better recruit and retain
providers. If the Administration waits too long, the competition will
become more intense. Therefore, the Friends of Indian Health sug-
gest that Congress take the following steps:
No. 1, make loan repayments tax free. Currently, the IHS pays
providers $20,000 annually, an additional 20 percent of that sum
to the Internal Revenue Service [IRS]. Totally, $3.4 million goes to
the IRS from the IHS loan repayment account. If the loans were
tax free, 170 more providers could be available.
No. 2, give IHS health care personnel 3-year student loan
deferments. Volunteers in programs like the armed forces, Peace
Corps, or Domestic Volunteer Service do not have to repay the
 8

principal of or the interest on any student loan for 3 years. This

provision does not apply to those working in IHS or for tribes. This
oversight can cost recent graduates more than $1,000 a month.
Faced with this burden, many health care professionals cannot af-
ford to join the IHS or work for tribes or urban programs.
No. 3, conduct exit interviews. As the IHS approaches the next
decade and must compete for health personnel, the Friends of In-
dian Health believes that it should require exit interviews deter-
mining whether staff are leaving because of non-competitive sala-
ries, high debt burden, inadequate housing, or lack of esprit de
corps would be essential to quickly making corrections to prevent
others from leaving.
No. 4, recruit active and retiring health care professionals inter-
ested in providing care on a part-time or temporary basis. The
American Academy of Pediatrics has received more than 300 re-
quests from active physicians for information about short-term pe-
diatric opportunities at IHS sites. Additionally, we believe that
many other providers are not ready to completely retire and would
be willing to volunteer 1 week, 1 day, 1 month, or even 6 months
to their service. Their experience and expertise particularly are in
high demand. The IHS needs to create a program where such vol-
unteers can be recruited, and assure them that liability would not
be a problem.
Mr. Chairman, the definition of insanity is doing the same thing
over and expecting a different outcome. Therefore, if, in fact, we de-
sire to make changes to produce different outcomes, we have to
begin today. The Friends of Indian Health believes our rec-
ommendations can move us in that direction.
Mr. Chairman and members of the committee, this concludes my
testimony. I will be happy to answer any questions you might have.
Thank you.
The CHAIRMAN. I thank you very much, Mr. Bird. I find your tes-
timony most enlightening.
[Prepared statement of Mr. Bird appears in appendix.]
The CHAIRMAN. May I begin my questioning with Dr.
Vanderwagen.
I gather that the pay scale of the IHS is tied to DOD; is that cor-
rect?
Mr. VANDERWAGEN. Yes, sir; thats true.
The CHAIRMAN. But does that include bonuses and cost of living
allowances?
Mr. VANDERWAGEN. For those that are in uniforms, the bonuses
and cost of living allowances are consistent with those provided to
the other uniformed services.
The CHAIRMAN. But what happens when there is no comparable
category to tie it in in certain areas?
Mr. VANDERWAGEN. Well, we have a variety of disciplines, for in-
stance, where there are no such bonus opportunities or other in-
ducements that we might provide, and that presents us with dif-
ficulty.
For instance, in nursing there really are no real financial incen-
tives like that provided through the DOD, so we dont have much
to offer on our side, either, for those that are in uniform.
 9

The CHAIRMAN. For many, many years DOD has been most reluc-
tant to have joint operations with the VA, and, as a result, we have
had VA hospitals and DOD hospitals. But now, with the cold war
over, many of our military hospitals have been destined to be
closed, and in order to keep them open some have become joint op-
erations with the VAfor example, in Hawaii. And the Hawaii op-
eration is a model operation.
Would you consider, where it is feasible, to have DOD have a
joint operation with IHS?
Mr. VANDERWAGEN. I believe that there are opportunities like
thatfor instance, in western Oklahoma. There are other locations
where there may be DOD facilities where, if tribal and urban peo-
ple had effective policy involvement in the development of those re-
lationships, I think we would be very interested in adding DOD
into the partnership.
The CHAIRMAN. Mr. Bird, would that be acceptable to Native
Americans?
Mr. BIRD. Well, I think it is something that one has to approach
very carefully, because I think there is some concern in terms of
most Indian populations that theyre going to end up losing out
when anything like this is explored.
I know in New Mexico, drawing on my 20 years of experience in
the IHS in the Albuquerque area, that there had been initial dis-
cussion back about 10 years ago about negotiating some sort of an
approach with the VA there in Albuquerque, and, as I best recall,
some of the tribes were concerned and actually kind of put a stop
to that because they felt like we wouldthe tribes, in fact, would
be losing out in some form or fashion.
I dont know if that was based on any real threat to the services
that were provided, but I think that there is that perception out
there in the community that somehow it will diminishpossibly di-
minish the Federal Governments role and responsibility to tribes.
But I know that that is a concern.
I think, given the times that we are looking at and the impact,
the adverse impact of lack of services for Indian people and Indian
populations thats occurring today, I think some tribes might be
more open to considering those options.
The CHAIRMAN. We will be thinking about that.
Mr. Vanderwagen, is there any partnering or collaboration be-
tween IHS and non-Federal agencies whenever there is a shortage
of specialties?
Mr. VANDERWAGEN. Yes; Im glad you asked that, because, while
Michael is here representing the Friends and he was unable to sort
of, in his prepared testimony, speak to some of the activities with
themfor instance, the American College of OB/GYN routinely as-
sists us in two ways. One is they will go out with us and do field
site visits to assess the quality of care, needed improvements in pa-
tient safety, protections, medication error management, and that
sort of thing, but they also have a program to provide OB/GYN spe-
cialists to assist us in locations where we have special needs.
The American Dental Association also has done very similar
kinds of site visitation with us and assisted us on a variety of clini-
cal care needs, as well.
 10

American Academy of Pediatricsa variety of these professional

organizations that constitute the Friends of Indian Health have
been tremendously helpful, both to the tribal programs and to the
Federal programs. I dont know that we have been able to link with
the urban programs as effectively as we might with these kind of
professional supports, and thats certainly an area where we could
work with the Friends of Indian Health to expand that relation-
ship.
The CHAIRMAN. We have an issue on the Federal Tort Claims
Act.
Mr. BIRD. Mr. Chairman?
The CHAIRMAN. Yes?
Mr. BIRD. Might I share some thoughts?
The CHAIRMAN. Sure.
Mr. BIRD. I wanted to mention that the American Public Health
Association has, since I became president of the association, has
been much more involved and much more engaged. There is, in
fact, an American Indian and Alaska Native, Native Hawaiian
Caucus, which has a 20-year history of association with the Amer-
ican Public Health Association. At our annual meeting this year in
Atlanta, which typically draws about 13,000 participants, for the
first time in 128 years there will be a plenary session on dealing
with indigenous health. Were attempting to have four representa-
tives from Native populations. Actually, there will be a Native Ha-
waiian physician who will be part of that program and a Canadian
representative and someone from South America to look at focusing
attention on indigenous health internationally, as well as within
this country.
The CHAIRMAN. All right. Thank you.
May I now go to tort claims? Is it true that the Department of
Health and Human Services can only approve settlements of less
than $25,000?
Mr. HILL. Yes; it is.
The CHAIRMAN. And yet you have testified that the median
amount is $1 million?
Mr. HILL. That is correct.
The CHAIRMAN. Then what should we do? Is something wrong
there?
Mr. HILL. Well, the current process allows them to settle for
those claims that are less than $25,000, but it does allow the De-
partment of Justice to handle claims in excess of that.
The CHAIRMAN. Then what happens?
Mr. MALCOLM. I think thats correct. Some agencies have looked
at whether that cap should be increased, kind of adjusting for infla-
tion type of methodology, given the increase in the claim amount.
Is the $25,000 gap still a reasonable amount for them to have that
authority?
The CHAIRMAN. How does it compare with the VA hospitals? Is
there a cap also for veterans going to VA hospitals?
Mr. MALCOLM. The restriction of the $25,000 would be for the en-
tire Federal Government, except where the Department of Justice
has delegated a higher settlement authority. The VA has been dele-
gated the authority to settle FTCA claims up to $200,000.
The CHAIRMAN. Is that the same with DOD hospitals?
 11

Mr. MALCOLM. To my knowledge it is the same, but Id have to

confirm that.
The CHAIRMAN. It is the same?
Mr. MALCOLM. To my knowledge it is the same.
The CHAIRMAN. Dr. Vanderwagen?
Mr. VANDERWAGEN. Yes; I agree with him. My understanding is
that thats a Federal-wide cap that independent agencies, short of
litigation going to the Department of Justice, have placed on them
for just settlement.
The CHAIRMAN. And what has been the experience with the Jus-
tice Department?
Mr. VANDERWAGEN. In general, our experience has been mixed.
Without getting too lengthy, we do an extensive quality review
process of any cases brought involving patient care, in particular,
and the Department of Justice has not been actively involved in
that review process with us, and there are times when we believe
that decisions are made despite the review process that weighs on
the merit of the case, and that has been of some concern to provid-
ers, because if Justice proceeds, despite the fact that the Quality
Review Panel does not believe theres merit against that individual,
they end up reported to the Practitioner Data Bank, whether they
were viewed as really having culpability or not, and thats a prob-
lem from the provider perspective, not speaking about the fiduciary
responsibility of the Government here, but provider concerns.
The CHAIRMAN. Is it because of this situation that you are not
able to fully utilize volunteers?
Mr. VANDERWAGEN. That is part of the situation. The other cir-
cumstance, you may be aware there was a malpractice suit brought
in a tribal court in New Mexico, and while the tribal council imme-
diately rejected trying that case within tribal court, it created con-
flict in the State of New Mexico over jurisdictional concerns, and
the insurance malpractice carriers for many providers, particularly
the pediatricians and obstetricians, since they were the two special-
ties involved in the case, have been real reticent to counsel their
members, their insured providers to practice. In fact, theyve dis-
couraged them from practicing in reservation environments.
The CHAIRMAN. And before I call upon the vice chairman, one
final question. Is there any medical school that specializes on In-
dian health? For example, you pointed out that there are problems
that you just discovered. Are there any medical schools that spe-
cialize on Indian health?
Mr. VANDERWAGEN. Sir, I believe there are one-half dozen insti-
tutions nationwide who really have shown tremendous commitment
and involvement in Indian communities through their participation
with tribes, as well as their participation with providers. Those
schools actually have developed a coalition now to explore ways
that they might more effectively support Indian health issues.
Without getting too extensive about it, it ranges from Hopkins
here in the east to the University of Washington to the southwest,
where Arizona and New Mexico have had real interests in Indian
health, and, of course, the University of Hawaii has trained a large
number of masters in public health and supported Indian health
concerns. So there are a variety of schools that have been very
helpful.
 12

The CHAIRMAN. Thank you very much.

Mr. Bird, the staff will be working with you on your rec-
ommendations.
Mr. BIRD. Thank you.
The CHAIRMAN. Mr. Vice Chairman.
Senator CAMPBELL. Thank you, Mr. Chairman.
While listening to your questions I was just musing to myself
about some of the people that I know who have been sick who have
needed help. I tell you, you take an average elder in an Indian
tribe who is not a very sophisticated person, a person that is close
to the land and close to their culture, and you start talking to them
when they come in about fiduciary responsibilities and the legal
ramifications and tort reform or tort problems and punitive dam-
ages and all that, I think theyre probably not going to understand.
All they know is theyre sick and need help. Somewhere weve got
to find a way to bridge that, you know, and give them more help.
I was interested in the chairmans question about if theres a
DOD program that you work with, and I was thinking of one that
has worked out really well. Its not directly with DOD, Mr. Chair-
man, but Fitzsimmons Military Hospital, as you know, in Denver
was a few years ago turned over to the University of Colorado.
They, in turn, with our help and funding from the Federal Govern-
ment, are building an American Indian diabetes center there now
for research and treatment, too, of diabetes among Indian people,
so I think theres some precedent set, maybe not a direct relation-
ship, but through working with local universities there are, I think,
some real opportunities.
Let me just scatter some of these questions around. You talked
earlier, Dr. Vanderwagen, about the recruitment program. As I un-
derstand from Mr. Hill, there is a problem with retention, too.
What is the reason? Is it low pay? Do they just go on to better
things? Do they get burnout from too many hours, like people in
the medical profession often do?
Mr. VANDERWAGEN. Well, I think it is a combination of those fac-
tors. I mean, entry level for a pharmacist, lets say, in Indian
health, they have to accept 30 percent lesser pay to come to work
for us than if they went to work for one of the retail chains in an
urban setting, so the pay is an issue.
Second, obviously, if theyre working in isolated environments
where spouses dont have the ability to get a job and so on, those
factors play in.
The concern, as I suggested earlier, about the severe rationing of
the system that Mr. Bird referred to and that you just spoke to
about an elder seeking service plays on providers severely. When
you continually have to pull people out of the river and you do not
have the opportunity to figure out how they got there in the first
place because youre just so busy trying to meet that flow, after a
while you do become tired. Theres no question about it.
I was just out in the Dakotas last week, and clearly that was a
message that I heard.
Senator CAMPBELL. Do most of them go to jobs in the private sec-
tor or just quit altogether?
 13

Mr. VANDERWAGEN. Its a combination of those factors that you

spoke to, and I think it is problematic to try and address each of
those.
Senator CAMPBELL. Let me ask again, the ones that do leave, do
most of them go into the private sector or just burn out and do
something else?
Mr. VANDERWAGEN. I think the majority of the people who leave
our system will go to another health care environment, just one
that meets their needs individually.
Senator CAMPBELL. When you do recruiting, do you do that on
the reservation?
Mr. VANDERWAGEN. The scholarship program, if you look at it
that way, yes, we do recruit that way. For certain jobs, skills that
are available in the community, thats clearly where we would re-
cruit. Thats part of the reason why 75 percent of the staff out
there are Indian people. We recruit from Indian communities for
Indian communities.
Senator CAMPBELL. We have tried to increase the IHS budget.
Weve put this year, I believe, $78 million more into the budget
than was in last year. Its probably still not enough. But does some
of that get to the salaries of the people that are in training?
Mr. VANDERWAGEN. Yes, sir; In fact, the highest priority that the
tribes, the urbans, and the Federal people developing the budget
the highest priority was lets make sure that the Pay Act for Fed-
eral employees and pay increases for tribal and urban employees
get covered. That has been the highest priority for expenditure.
Senator CAMPBELL. Let me ask you just a question or two about
the urban Indian community. Mr. Bird, you know, a personan In-
dian persongets sick in Albuquerque, its not a long-distance trip
usually to go back to the Pueblos. A lot of them are pretty close.
But our biggest city is Denver, we have roughly 25,000 Indian peo-
ple who live in Denver. The nearest Indian clinic, reservation clin-
ic, is I guess about 250 miles away, the Southern Ute clinic way
down at the end of the State. They cant just go home when they
get sick. Theyve got to go downtown.
Do you do any interaction working with local health clinics for
Indian people that need help that cant go home? Or do you do any
kind of an outreach program so that Indian people know where
they can go if theyre in the city and need help?
Mr. BIRD. Yes; well, without getting too wordy, we do fund 34
urban Indian programs whose primary mission has been initially
to institute an outreach process and provide a way to coherently
assist Indian patients. Some of those now have expanded into fully-
functioning, ambulatory, primary care facilities. In fact, 14 of them
are now federally-qualified health care facilities under the HCFA
guidelines. So that is exactly what the intent of the act, as we un-
derstood it, title V was, and thats what weve tried to work with
the urban programs to accomplish.
Senator CAMPBELL. I see.
Mr. Hill, whats the average time that claims are settled now?
Mr. HILL. We dont have a general timeframe. The process is ba-
sically when the claim is filed HHS has 6 months to decide, and
certainly a number of those are spilling over that 6-month period,
 14

but after the 6-month period expires the claimant can then go and
file suit in court to get it settled.
Senator CAMPBELL. Whats the longest you would say it takes to
get a claim settled?
Mr. HILL. We found five claims that were filed in fiscal year 1997
that were still pending. That makes them almost 4 years old.
Senator CAMPBELL. Dr. Vanderwagen, you know, there has been
some discussion. In fact, there is a bill in to elevate the IHS direc-
tor to Assistant Secretary in the HHS. Would that be a priority in
the Indian health community?
Dr. VANDERWAGEN. In consultation with the tribes and the urban
folks, that clearly, from their perspective, is a priority to elevate
the director to an Assistant Secretary level.
Senator CAMPBELL. Do you have a personal view on it?
Mr. VANDERWAGEN. I think there are real pluses in terms of the
kind of partnership and access to a wide range of departmental
programs that could be facilitatedfor example, alcohol programs
that cross the Department and other kinds of health programs.
There appears to be some merit in the proposal from that perspec-
tive.
Senator CAMPBELL. There are two demonstration programs, Dr.
Vanderwagen, in Oklahoma that are, as I understand, operated a
little differently from the normal programs in the IHS that I un-
derstand are very successful. How are they different and what
makes them so successful?
Mr. VANDERWAGEN. Well, thank you for asking. Those are inter-
esting and, I think, unique programs.
In the past, Congress provided authority for those programs to
not only be dealt with under title V as urban programs, but to be
dealt with as service units under the Federal process. That means
that they could access resources not only limited to the title V
budget authority but to all the other budget authorities within the
agencyhospitals and clinics, mental health, et cetera.
The plus side of that has been that it has allowed them to ex-
pand and become more comprehensive using IHS funds in address-
ing the health needs of individual urban Indians in Tulsa and
Oklahoma City, and therefore reduce the requirement for them to
seek funding from other sources, to some degree.
Senator CAMPBELL. Theres supposed to be a report made on
those demonstration projects, too, as I understand it. Is that report
finished? Im told it is.
Mr. VANDERWAGEN. Yes, sir.
Senator CAMPBELL. And when are we going to get a copy of that
report.
Mr. VANDERWAGEN. I would have to check on that, but I could
provide you an answer for the record, sir, as to when that would
be available. Im just ignorant at the moment of that.
Senator CAMPBELL. To your knowledge is there any opposition to
launching more programs along the lines of those demonstration
programs?
Mr. VANDERWAGEN. It is a complicated issue with regards to trib-
al sovereignty and the responsibilities and authorities of tribal gov-
ernments vis-a-vis individual Indians who may be in urban settings
and how those programs access resources. This is a real difficult
 15

issue, not just involving Oklahoma and Tulsa, but I think all of the
Indian health system at this point, the balance between tribal gov-
ernment and the government-to-government relationship and the
needs of individual Indian people who happen to live in urban set-
tings. Its very difficult.
Senator CAMPBELL. Well, if they have been successful, there is a
good possibility that we could expand that program, then.
Mr. Bird, tell me a little bit more about this. Which organization
participated in this, as you called it, Friends Organization.
Mr. BIRD. Yes.
Senator CAMPBELL. Whats their interest in the Indian health
field?
Mr. BIRD. Well, their interest is in seeing that, in fact, the needs
of American Indian and Alaska Native people are better met, and
there isits a broad coalition, as was mentioned before, of the
American Dental Association, American Association of Colleges of
Nursing, American Hospital Association, American
Senator CAMPBELL. All of them have some health connection?
Mr. BIRD. Yes; all involved in the health arena. I will submit a
copy. I do have a list of the members of Friends of Indian Health.
Senator CAMPBELL. Great. Please submit a copy of that. Well try
to make that a part of the record.
Did you go out and recruit those people to help, or is that some-
thing they put together themselves and volunteered to do?
Mr. BIRD. Its actually something that the American Dental Asso-
ciation put together, has been active for a number of years because
of their interest and their recognition of the fact that theres great
disparity in American Indian and Alaska Native communities.
Senator CAMPBELL. I see.
Mr. BIRD. And they are to be commended because they are a very
active, viable group, and at their behest I am here today.
Senator CAMPBELL. Okay. Swell.
Thank you, Mr. Chairman.
The CHAIRMAN. I thank you very much.
I have a few more questions.
Mr. Vanderwagen, do you have any thoughts on Mr. Birds rec-
ommendation on having Indian volunteers be on the same par as
Peace Corps workers and others?
Mr. VANDERWAGEN. Well, thats a refreshing notion and one that
we have not explored, but it certainly seems to have some merit.
Again, bringing people in, we believe that our mission and the
work that we do is such a blessing in life that if we bring those
people in were likely to keep them for longer than just a simple,
short-term stint.
The CHAIRMAN. Will you have your staff look at Mr. Birds rec-
ommendations and give us your thoughts on this?
Mr. VANDERWAGEN. Yes, sir; I will.
The CHAIRMAN. Are you aware of other federally-sponsored loan
repayment programs that are tax free?
Mr. VANDERWAGEN. I believe that there have been programs
funded through the Health Resources and Services Administration
that has had some tax-free loan repayment components, but I may
be wrong about that, but thats what comes to mind.
 16

The CHAIRMAN. Then you do not mind if you are on a level play-
ing field?
Mr. VANDERWAGEN. If wed get back onto a level playing field Id
be real happy.
The CHAIRMAN. Well, Mr. Bird, it appears that you have a few
allies here.
Mr. BIRD. Im glad to hear that.
The CHAIRMAN. Now may I ask Mr. Hill a few questions. Does
the Tort Claims Act provide malpractice coverage for retired pro-
viders who practice on a part-time basis for a contractor?
These questions are asked because I have had letters from In-
dian country.
Mr. MALCOLM. Yes, Mr. Chairman; the Federal regulations that
were issued on thisits 25 CFR, part 900, subpart M talks about
the types of people, both for medical and non-medical claims, that
are covered. It specifically states that temporary employees, if they
are working under a self-determination contract for a tribe, would
have tort claim coverage.
The CHAIRMAN. They are covered?
Mr. MALCOLM. Yes; if they are performing a service under a self-
determination contract.
The CHAIRMAN. Now, does this act also provide coverage for med-
ical specialists, as well as primary care providers?
Mr. MALCOLM. I believe so. Again, depending ona lot of very
legal technical terms apply to this area, and thats why theres a
lot of confusion, and the Department of Justice basically has to
make determinations on a case-by-case basis.
If the specialist, again, is working at the tribal facility, then
clearly there would be that coverage. If that specialist is basically
at a hospital in town thats not a tribal facility, there would be
questions about the coverage in that case.
Again, its the function that is being performed. If its being per-
formed under the tribal contract, there would be coverage either for
full time, part time, or volunteers. When tribal members are get-
ting care from people outside of that contract, then there would be
questions about the coverage.
The CHAIRMAN. Does it make any difference as to the venue of
the care in the tribal hospital or some other hospital?
Mr. MALCOLM. Yes; it would. If that person is not directly work-
ing under the contract, there would bethat would be an issue.
The CHAIRMAN. Mr. Hill, you indicated that volunteers working
at a tribal facility will have tort claim coverage?
Mr. HILL. That is correct, as long as theyre working under a con-
tract.
The CHAIRMAN. Dr. Vanderwagen suggested that, because of this
tort claim issue, volunteers are reluctant to sign up. How are these
claims examined that involve volunteers?
Mr. HILL. I cant answer that. Of the 114 claims that we identi-
fied, none of them involved volunteers, so Im not sure it has been
tested yet.
Mr. VANDERWAGEN. If I may, Senator, its a climate of anxiety
that is not fully assuaged by Justice approach of decision on a case-
by-case basis, and many providers are unwilling to accept the sort
of verbal assurance that, Oh, yes, you will be covered, but we re-
 17

serve the right on a case-by-case to approach these issues, and it

is that lack of absolute certainty that is chilling for many people,
particularly in light of their private insurance carrier counseling
them that they are entering into an extremely risky environment.
So the cases really have not been directly challenged. It is more
a climate of concern and anxiety that were trying to attend to on
these matters.
The CHAIRMAN. Mr. Hill, do you have any response to that?
Mr. HILL. No. Thats correct. We would agree with that. We
would note there are some other special coverage provisions that
apply. For example, in California, where you have a lot of contract-
ing the California Indian Rural Health Board basically provides
services there, and then they have subcontractors. As a general
rule, under FTCA subcontractors would not be covered; however,
Congress has made special provisions for California that those sub-
contractors will be covered.
We did find, during the 3 years we looked at, that there were 10
claims from subcontractors of the California Indian Rural Health
Board that had been provided coverage. So there are other special
mechanisms in there for IHS programs, and we did find that those
are working as they should be.
The CHAIRMAN. Then do you feel that the problem expressed by
Dr. Vanderwagen can be resolved or addressed legislatively?
Mr. MALCOLM. I dont believe so. Part of the problem is, again,
as Dr. Vanderwagen mentioned, there is a large amount of confu-
sion and misunderstanding about the coverage, and a lot of the
legal questions about who is covered and who is not covered, that
actually hinges on State law. So, depending on the location of
where the incident occurred, the Justice Department or HHS, the
Office of General Counsel, will look to the State law as far as the
definition of who is an employee and what functions that person
has to be performing to be considered an employee, so the State
law is the controlling issue there historically, so thats what they
look to and thats why there could be differences from State to
State, and thats a case-by-case basis.
The CHAIRMAN. Are volunteers at VA or DOD hospitals treated
the same?
Mr. MALCOLM. Our study didnt really include VA and DOD, so
Ill have towed have to look into that further.
The CHAIRMAN. My final question on urban Indian programs has
to do with a letter that was received by the staff. Are urban in
health care centers deemed to be ordering agents of the IHS for the
purchase of pharmaceuticals?
Mr. VANDERWAGEN. In general they have not been direct partici-
pants in the special purchasing arrangements that we have
through the VA, the prime vendor, which gets the absolute lowest
cost. The 638 relationships provide us the authority to do that, and
the majorityobviously, the urban programs are generally under
the buy-Indian provision, and theyve not been included with the
VA purchasing arrangements to date.
The CHAIRMAN. Is there any reason for that?
Mr. VANDERWAGEN. Primarily revolving around the authority, in
their view, being Federal, and 638 qualifying tribes as Federal, as
 18

it does in many other environments, but the buy-Indian contracting

not viewed in the same way by the Veterans folks.
The CHAIRMAN. Can this matter be resolved internally?
Mr. VANDERWAGEN. We are working on it and we think we might
be able to get a solution, but thats certainly something we can re-
port to you on.
The CHAIRMAN. Mr. Bird, are you satisfied?
Mr. BIRD. Yes.
The CHAIRMAN. Your negotiations are bearing fruit?
Mr. BIRD. We need more trees.
The CHAIRMAN. Well, well try our best, sir.
Mr. BIRD. Thank you.
The CHAIRMAN. We have a few more questions wed like to sub-
mit, if we may, and receive your response.
Senator CAMPBELL. May I ask one more?
The CHAIRMAN. Yes, please.
Senator CAMPBELL. Let me ask one final question, Mr. Chair-
man. Since you had mentioned Peace Corps, originally when Peace
Corps was set up it dealt with helping people in foreign countries.
There was another program called Vista that was very similar,
but it was more domestic oriented, and Vista workers at that time
some years ago actually were working on reservations.
I dont know if Vista program is still in effect or if it has been
superseded by Americorps or some of these other groups such as
the National Health Care Service Corps or so on, but do any of
these groups take part in the Indian health profession, Dr.
Vanderwagen? Or do you work with any of those groups at all?
Mr. VANDERWAGEN. No; we really have not had formal relation-
ships with them, and an interesting idea that we have not ex-
plored.
Senator CAMPBELL. Do you have the legislative authority now to
be able to work with them, or do you need something from us in
order to do it?
Mr. VANDERWAGEN. Well, Id have to defer to our legislative peo-
ple on that, but we could certainly provide an answer back to you
on that question.
Senator CAMPBELL. Would you find out for us, because it seems
to me that there are a lot of good-willed, hard-working people that
want to help out there, and if we could get them involved with you
so you could utilize some of their folks, I think it would be good
for you and maybe good for Indian country, too. Find out if we need
to do something legislatively or if you can just go ahead and do it.
And if you can, I would encourage you to do it.
Dr. VANDERWAGEN. Well do.
Senator CAMPBELL. Thank you.
Thank you, Mr. Chairman.
The CHAIRMAN. All right. Thank you very much, gentlemen.
Mr. VANDERWAGEN. Thank you.
Mr. HILL. Thank you.
Mr. BIRD. Thank you.
The CHAIRMAN. Before I call upon the next panel, without objec-
tion the opening statement of Senator Kent Conrad will be made
part of the record.
[Prepared statement of Senator Conrad appears in appendix.]
 19

The CHAIRMAN. And now may I call upon the second panel: The
president of the National Council of Urban Indian Health, Robert
Hall; the health director of the American Indian Community House
in New York, Anthony Hunter; the executive director of the Mis-
soula Indian Center of Missoula, MT, Carole Meyers; the executive
director of the Native American Health Center, Oakland, CA, Mar-
tin Waukazoo; and the executive director of the Denver Indian
Health and Family Services, Incorporated, of Denver, Kay
Culbertson.
May I call upon President Hall.

STATEMENT OF ROBERT HALL, PRESIDENT, NATIONAL

COUNCIL OF URBAN INDIAN HEALTH, WASHINGTON, DC
Mr. HALL. Thank you, Mr. Chairman, Mr. Vice chairman, and
also for the Senator of my home State, Senator Conrad, when he
was in here for a while. My name is Robert Hall. I am the presi-
dent of the National Council of Urban Indian Health and a member
of the Three Affiliated Tribes from Fort Berthold, ND. My tribal
heritage is Arikara and Hidatsa. The third tribe up there is
Mandan. I also have some prepared remarks I have submitted for
the record. I am also the executive director of the South Dakota
Urban Indian Health Clinics. I wish to thank you for this oppor-
tunity to address the committee on the reauthorization of the In-
dian Health Care Improvement Act, S. 212.
Id like to take a moment to introduce you to our new executive
director for the National Council of Urban Indian Health, a lady
I think you are very familiar with, Beverly Russell. Were very
pleased for the training she received while she was interning with
you.
The CHAIRMAN. Shes a good lady.
Mr. HALL. Yes.
The CUIH is the only membership organization representing
urban Indian health programs. Our members provide a wide range
of health services and care, ranging from information and outreach
to full clinics. We provide referral services in 34 cities, not counting
the new program in Hawaii, to a population of approximately 332
urban Indians. We are often the main source of health care and
health information for these urban Indians. According to the 1990
census, 58 percent of American Indians lived in urban areas. We
expect that number to be well over 60 percent in the 2000 census
results.
Like their reservation counterparts, urban Indians historically
suffer from poor health and substandard health care services.
In 1976, Congress passed the Indian Health Care Improvement
Act. The original purpose of this act, as set forth in a contempora-
neous report, was to,
raise the status of health care for American Indians and Alaska Natives over a
7-year period to a level equal to that enjoyed by other American citizens.
It has been 25 years since Congress committed to raising the sta-
tus of Indian health care and 18 years since the deadline has
passed for achieving the goal of equality with other Americans, and
yet Indians, whether reservation or urban, continue to occupy the
lowest rung on the American health care ladder.
 20

Although the road to equal health care still appears to be a long

one for Indians, the CUIHthe National Council of Urban Indian
Healthbelieves that S. 212 is a step in the right direction. As a
general matter, NCUIH supports S. 212, although we do rec-
ommend certain changes to maintain Congress commitment to
urban Indians.
The Indian Health Care Improvement Act currently provides
that it is the policy of the United States to achieve the highest pos-
sible health care for both Indians and urban Indians; however, S.
212 does not contain a reference to urban Indians in its equivalent
paragraphs. Deleting urban Indians from this policy statement, es-
pecially since urban Indian is a defined term in the legislation,
could imply that the Congress no longer considers the health status
of urban Indians to be a national priority.
NCUIH strongly urges the restoration of urban Indian to sec-
tion 3, paragraphs 1 and 2, of S. 212.
NCUIH is generally satisfied with the definition of urban In-
dian in S. 212, although certain language in the definition appears
to limit its coverage to title V of the legislation. Urban Indians are
referred to in other titles of this legislation; therefore, this limiting
language should be removed.
NCUIH supports an amendment to S. 212 that would grant
urban Indian health programs the same 100 percent Federal medi-
cal assistance percentage as is currently enjoyed by IHS facilities
and IHS 638 contractors.
Like IHS facilities, urban Indian programs exist because of the
Federal responsibility in the Indian health care area. We should be
treated the same as IHS for the purposes of FMAP, and we would
like to thank the chairman for his support in introducing FMAP
legislation.
NCUIH supports expanded authority in funding for urban Indian
health programs in the area of pharmaceutical services. Such ex-
panded authority would result in an immediate elevation of the
quality of care for these communities, especially the elderly.
NCUIH supports the establishment of the National Bipartisan
Indian Health Care Entitlement Commission. The work of this
commission will help provide the basis for a rational and effective
approach to Indian health care well into the 21st century.
Although addressed in other Senate legislation, we would like
you to know that NCUIH strongly supports the elevation of the di-
rector of the IHS to Assistant Secretary for Indian health. Too
often Native voices are lost in the national clamor over health care
policy and funding. Elevating this position would greatly strength-
en the voice of Indian country, whether in the halls of Health and
Human Services, the corridors of Congress, or wherever the health
care debate occurs.
In fiscal year 2001 urban Indian health programs received 1.14
percent of the total IHS budget, although urban Indians con-
stituted at least 50 percent of the total American Indian popu-
lation.
NCUIH acknowledges that there are some sound reasons why
the lions share of the IHS budget should go to reservation Indians;
however, the health of Indian people in urban areas affects the
health of Indian people on reservations and vice versa. Disease
 21

knows no boundaries. NCUIH strongly believes that the health

problems associated with the Indian population can be successfully
combated if there is significant funding directed at the urban In-
dian population, as well as reservation population. To address this
need, NCUIH has asked for a $5 million increase in the urban In-
dian health line item in its 2002 budget.
NCUIH also supports the establishment of a 5-percent set-aside
of the IHS diabetes funding to be provided to urban Indian diabe-
tes programs, and we would like to acknowledge the vice chairman
for his strong letter directing that.
In the chart in front, you will see a history of IHS funding and
urban Indian health funding from 1979. You will notice in 1979 our
funding comprised 1.48 percent of the total IHS budget, and you
can see from the graph were back down into a dive in falling be-
hind, not even maintaining. And you also are very aware that the
IHS budget isnt maintaining a level track with increased cost.
America is nowhere near the lofty goals set by the Congress in
1976 of achieving equal health care for American Indians. Whether
reservation or urban, NCUIH challenges this committee to think in
terms of that goal as it considers reauthorization of the Indian
Health Care Improvement Act.
NCUIH thanks this committee for this opportunity to provide
testimony on S. 212, and we strongly urge positive action on the
matters we are addressing today.
I would like to take this opportunity to thank both the majority
staff in the committee and the minority staff in the committee for
being very cooperative and helpful in establishing this hearing and
in working with our members.
Thank you.
The CHAIRMAN. I thank you very much, Mr. Hall.
[Prepared statement of Mr. Hall appears in appendix.]
The CHAIRMAN. May I now call upon Mr. Hunter.
STATEMENT OF ANTHONY HUNTER, HEALTH DIRECTOR,
AMERICAN INDIAN COMMUNITY HOUSE, NEW YORK, NY
Mr. HUNTER. Good morning, Mr. Chairman and members of the
committee. We want to thank you for inviting us to testify at this
important hearing on urban Indian health programs. We would
also like to recognize and thank you for your support of our pro-
grams over the years.
With your permission, I will submit my written testimony and
make additional verbal comments.
Id like to familiarize you with the American Indian Community
House because we have not only health programs but also cultural
enrichment programs. We use an innovative approach in order to
combine these to meet our communitys needs.
The American Indian Community House is a 501(C)(3) not-for-
profit organization serving the health, social service, and cultural
needs of Native Americans residing in New York City. AICH was
founded in 1969 by Native American volunteers as a community-
based organization mandated to improve the status of Native
Americans and to foster inter-cultural understanding.
Since its inception, AICH has grown into a multi-faceted social
support agency, cultural center, and it has a staff of 35.
 22

AICH membership is currently composed of Native Americans

from over 80 different tribes and represents a service population,
according to the 2000 census figures, of 59,000 Native Americans
who reside in the greater New York City metropolitan area.
Native American migration between urban centers and reserva-
tions demonstrates the inter-relatedness of all Native Americans,
and from this reality emerges the recognition that our issues and
concerns are truly shared.
The AICH philosophy is that solutions can be shared, as well.
AICH uses an innovative approach in combining the objectives of
our social service and cultural enrichment programs to meet that
communitys multi-faceted needs.
AICH provides programs in job training, placement, health serv-
ices referral and advocacy, HIV referral, case management, and
counseling programs for alcoholism, substance abuse, and mental
health. AICH also sponsors programs in cultural enrichment
through a performing arts program and the only Indian-owned and
-operated Native American gallery museum in New York City.
These programs are important to us, because a large percent of our
population comes to New York City specifically because they are in-
volved in the performing and visual arts.
A secondary but no less important focus of AICH is to educate
the general public about contemporary as well as historic American
Indian issues and peoples. Some of the departments that I spoke
aboutand Ill give you a little more detail, if I may, on those
our HIV/AIDS project, for example. In response to the increasing
numbers of Native Americans living with HIV and AIDS, the HIV/
AIDS project provides community prevention, outreach, education,
and information, targeted outreach to individuals at risk, and serv-
ices to those infected. The project offers referral to drug and alcohol
programs, sexually transmitted disease clinics, test sites, general
health and mental health care facilities.
They also offer services for gay and lesbian Native people. At one
of our recent community meetings, it was our understanding that
we need to expand our services for gay and lesbian Native people
living in New York, and that its not just HIV and AIDS that our
agency needs to be concerned about when serving that population.
Case management services are also offered and provided in New
York City, as well as program offices in Buffalo, Syracuse,
Riverhead, and the Akwesasne Mohawk Reservation.
AICH is actually very unique, I believe, as one of the urban pro-
grams in that we offer services also on the reservation. We have
historically offered also Department of Labor services on the
Shinnecock Reservation in eastern Long Island.
The employment and training funding by DOL provides edu-
cational services as well as training focused on preparing an indi-
vidual for the job market. Interview skills, resume writing, com-
puter training, referrals to outside job training facilities, limited
tuition and support for higher education, and job placement assist-
ance are among those services. We are beginning a process of be-
coming a training facility registered with the New York State Edu-
cation Department.
Our health department is staffed by community health rep-
resentatives, or CHRs, and their work includes health education,
 23

medical and dental referrals, community outreach, and the develop-

ment of Native American specific health oriented materials.
The Health Departments alcohol and substance abuse program
services strongly focus on group and individual counseling. These
programs offer a sense of community support as the Native Amer-
ican people seek to begin and maintain their recovery.
Spiritual and cultural support are integral parts of the programs,
as well as our education and prevention activities, and other pro-
grams within the Health Department include mental health, the
AICH Youth Council and Theater Project, our daily food and cloth-
ing bank, and hot lunches for community members.
According to our recent behavioral risk factor survey sponsored
by IHS and Centers for Disease Control, prevalent in our popu-
lation are risk factors associated with heavy cigarette smoking,
sedentary lifestyle, acute alcohol use, and drinking while driving.
Using AICHs innovative approach in combining health prevention
and cultural activities, we will now design prevention programs
specifically addressing these behaviors using the visual and per-
forming arts.
As part of the Health Department, we have a Womens Wellness
Circle project, and it is specifically for Native women. Utilizing in-
novative and cultural-specific strategies again here in this pro-
gram, the project works to develop a network between AICH,
health institutions, other front-line providers, and Native women in
the community. The project provides accessible satellite screening
and health information through mobile units, develops Native edu-
cational performance pieces, holds monthly wellness circles for Na-
tive women to share access concerns and to provide preventive
health education.
The AICH gallery museum is the only Native American owned
and operated gallery in New York City. It exhibits the finest in
contemporary and traditional art in every media by both emerging
and established Native American artists. The gallery presents a
minimum of four exhibitions a year and presents artists lectures
and forums on contemporary Native arts and issues.
The artwork on exhibit is often for sale, and we charge only a
small commission on those sales.
Our Performing Arts Department, which is actually part of our
Department of Labor program, theyve actually been very liberal
with us in the way we operate and the way we combine program-
ming, and the Department of Labor, or what is now the WIA
Workforce Investment Act programis really the backbone of our
organization over the years, since we first received Federal funding
in 1975.
The Performing Arts Department coordinates various cultural ac-
tivities featuring Native American performing arts and promotes
and assists all Native ensembles, such as Spiderwoman Theatre,
Thunderbird American Indian Dancers, Coatlicue Theatre, and
Ulali. The Department provides referrals for Native storytellers,
musicians, and lecturers. It acts as a non-paid booking agent for
Native actors, dancers, and models, and provides rehearsal space
and technical assistance to Native American artists.
We have a main stage that we have as a moveable space within
our agency that seats up to 150 people during performances.
 24

We also have a legal service project for Native Americans in our

community, which is actually a joint project between AICH and the
American Indian Law Alliance. The legal services project is in its
fourth year of providing free legal referral services to Native Amer-
icans. The project assists with all types of legal matters for Native
people in an urban environment, including but not limited to hous-
ing, Indian Child Welfare Act, and Jay treaty issues. The Jay Trea-
ty, as a matter of fact, has been something that the American In-
dian Law Alliance has been looking at very closely, and theyre de-
veloping further information on this.
In our population we have a large number of Indians that come
from Canada, and since they are eligible to receive services in the
United States, we advocate for that service for them by not only
attending hearings on their eligibility requirements, but also doing
outreach with departments such as Social Security Administration
to educate them and their workers about the eligibility of Canadian
Indians living and residing in the United States.
On behalf of the Native American community of the New York
City metropolitan area, Id like to thank you for your consideration,
and as you go about considering the needs of urban Indians Id like
to just mention that some of the most important issues that we
have are support of the Jay Treaty and its rights. Were also hav-
ing an urban planning meeting coming up in August that will be
attended by representatives of IHS, the Health Care Financing Ad-
ministration, our State alcohol program, and the Bureau of Man-
aged Care Planning to help AICH decide how it can move forward
in its licensing and third-party billing process.
And, of course, the Indian Health Care Improvement Act reau-
thorization is an integral part of AICHs future and its ability to
serve its community.
Thank you.
The CHAIRMAN. I thank you very much, Mr. Hunter.
[Prepared statement of Mr. Hunter appears in appendix.]
The CHAIRMAN. Ms. Meyers.
STATEMENT OF CAROLE MEYERS, EXECUTIVE DIRECTOR,
MISSOULA INDIAN CENTER, MISSOULA, MT
Ms. MEYERS. Thank you. Honorable Chairman, committee mem-
bers, my name is Carole Meyers. Im the executive director for the
Missoula Indian Center, Missoula, MT. I am an enrolled member
of the Blackfeet Tribe and a descendent of the Oneida and Seneca.
I want to thank you for this opportunity to come before you today.
Missoula Indian Center is a nonprofit organization. It has been
in existence in Missoula, MT, for the past 31 years. The organiza-
tion has assisted with health referrals to the 3,100 Native Ameri-
cans that reside in that area. We have approximately 65 tribal rep-
resentation throughout the Nation that come to our community. Its
also the home of the University of Montana, of which many of our
Native American clients come and attend.
Montana has seven reservations, and of the reservations there
are 11 different Native American tribes represented in each area.
When Native Americans leave their home reservation and move
to an urban area such as Missoula, they face many obstacles. One
of the most noticeable is their health coverage. Once they leave the
 25

reservation and live in an urban area for more than 180 days, they
lose their health coverage through the IHS.
Some of the programs that we provide through our program is
immunization, health promotion and disease prevention, AIDS, al-
cohol and mental health, diabetes, and our chemical dependency
programs.
Missoula Indian Center is governed by a 7-member board of di-
rectors, of which 51 percent must be Native American. Missoula In-
dian Center is organized under two major programs, which is our
health program and our chemical dependency. We have 11 full-time
staff and one part-time mental health counselor.
Health issues that surround our Native American clients range
from diabetes to the common cold. With our agency as a health re-
ferral organization, many of our clients see up to three to five dif-
ferent health providers in the course of a year. With this inconsist-
ency of health providers, there is not a medical health history that
follows our clients as they go to their medical provider. This creates
more confusion and lack of medical knowledge of a clients history.
Many times, because lack of funding, clients will be referred to at
a point of emergency in their situation. There is little prevention
health coverage, such as yearly physicals or dental checkups.
Missoula Indian Centers health program provides quarterly clin-
ics that cover the basic health issues, which in itself is an excellent
program but a significant problem that we are faced with is if a
client comes up with a problem through their medical checkup, we
cannot provide the resources to do the maintenance or followup,
such as when they do a blood screening. If they come back and
there is an issue that they need to do followup with a medical doc-
tor, we basically have to tell them they have to go back to the res-
ervation or seek medical assistance on their own.
It is safe to say that 80 to 90 percent of our clients do not have
health coverage or insurance.
The Missoula Indian Center had 8,865 encounters this past year.
These encounters are community members who accessed the center
for medical issues, drug and alcohol counseling, all the way up to
utilizing the telephone. We are looked upon as a one-stop agency
for many of our needs other than medical.
Other issues besides health issues that our clients face are hous-
ing, employment, school, K12 and higher education, law enforce-
ment, and food.
Presently, we contract with the health agencies such as Partner-
ship Health at a reduced cost for our doctors visits. This enables
health funds to cover more clients over the course of 1 year, but
this does not address the clients need for medical followup or
maintenance, as I discussed earlier.
When a client needs to have a prescription filled, we are able to
transport them to St. Ignatious, which is located on the Flathead
Indian Reservation. This entails a 90-mile round trip. Because of
the Salish and Kootenai tribal policies, clients have to physically
present themselves at the pharmacy in order for their prescription
to be filled. This creates hardship with our clients for two reasons:
No. 1, they may not have a vehicle to transport themselves up; and,
No. 2, they may not have gas to put in their vehicle to make the
90-mile round trip.
 26

Other services that we seek for our clients to try to utilize on the
Flathead Reservation is the dental clinic, but in order for a client
to be seen they have to leave the Missoula area at 7 in the morning
to be there at 8 a.m. to be seen in an emergency dental situation.
Once again, for them to utilize it, it is an emergency, either a
toothache or some type of infection. Theres no or little prevention
for our dental.
In our chemical dependency programs we offer intensive out-
patient and standard outpatient groups and some individual coun-
seling. Our programs are Montana State certified, so were able to
see non-Native American clients, which we do some billing with
that particular population.
Our programs are spiritually and culturally themed, and many
of the agencies other than our programs that provide counseling
make comment that the uniqueness of the counseling sessions do
help with the holistic approach with recovery of the addiction, and
they have been noted for this in the State of Montana.
When clients come in to utilize these alcohol programs, they not
only bring their addiction but they bring many, many health prob-
lems, and we are seeing more diabetics in this course of our target
population in this area.
I want to just interject this personal note. My father who is 82
years old has been a diabetic since the mid 1970s. My mother is
79 years old and she has been diagnosed with diabetes for the last
15 years. My father is a World War II veteran, has been an ad-
mirer of yourself, Senator Inouye, and this Commission for many
years and thinks of you as a champion on issues that pertain to
the American Indian. He has made comment that he would like to
leave the reservation, but because of the lack of health coverage in
the urban areas he is unable to leave the hospital in Browning,
Montana, because that is his life support for he and my mother.
I want to thank you for your time for listening and reading my
testimony. It has been a privilege and an honor to come before you
with my thoughts and ideas. Each and every day Native Americans
are faced with issues and problems of health, employment, and
education. I sincerely hope with my testimony that our issues have
been personalized. Survival on a day-to-day basis for Native Amer-
ican people is a very real issue.
Thank you.
The CHAIRMAN. Thank you very much, Ms. Meyers.
[Prepared statement of Ms. Meyers appears in appendix.]
The CHAIRMAN. May I now recognize Mr. Waukazoo.
STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR,
NATIVE AMERICAN HEALTH CENTER, OAKLAND, CA
Mr. WAUKAZOO. Thank you, Mr. Chairman and Mr. Vice Chair-
man. My name is Marty Waukazoo, and I am an enrolled member
of the Rosebud Sioux Tribe in South Dakota. I was born and raised
in South Dakota. I moved to California in 1973 and have been the
executive director of the Urban Indian Health Board since 1982.
My wife and I have three children and two grandchildren. My wife,
Helen, is the executive director of the Friendship House Associa-
tion of American Indians in San Francisco, which is an alcohol an
drug rehabilitation center partially funded by the IHS.
 27

The American Indian community in the Bay area organized and

incorporated the Urban Indian Health Board in 1972 to open the
first Native American health center in San Francisco. In 1976, a
second clinic was opened in Oakland, CA. Today, the Native Amer-
ican Health Centers are a full-service clinic with locations in Oak-
land and San Francisco, dedicated to making health services avail-
able to the American Indian community of the five Bay area coun-
tiesMarin, Contra Costa, San Mateo, Alameda, and San Fran-
cisco.
The services we offer include medical, dental, mental health, nu-
trition, community health education, youth services, and women,
infants and children program, or WIC program.
In 1983, the urban Indian Health Board had an annual operating
budget of $827,000, with 17 employees. Of this amount, 90 percent
was funded through grants and contracts from IHS. Today our an-
nual operating budget is $7.1 million, with 120 employees. Of that,
14 percent or $960,000 is through grants and contracts from the
IHS. Of the 120 employees we have, 65 percent are American In-
dian. For every dollar that the IHS invests in us, we are able to
leverage six additional dollars.
We are much more than just a medical clinic. We are also the
cultural hub of the Bay area. When an Indian person comes to the
Bay area looking for jobs from the reservations, coming to the
urban area for training, the first question they ask is where is the
clinic, because they know thats where you can renew friendships,
get acquainted, and find someone who can connect you up with
other services.
Within the Bay area Indian community there is a social service
network. When I, as a Lakota or a Sioux and someone from my
State comes to visit us in the area, when they walk up to me and
they find me Im obligated to help that individual navigate through
the city system or through the local health care delivery system,
so it is really a point of access for our community that we serve
over and beyond that of just a health clinic.
As I said, the Native American Health Center in the Bay area
is one of the largest, if not the largest, employer of American Indi-
ans in the Bay area. We not only offer employment opportunities,
but we also do dental assistant training, medical assistant training,
clerical training. We do training within our organization. Many of
our employees are former patients of our clinic. It was very impor-
tant for us that we have that balance of having that opportunity
and giving preference, not only Indian preference, but also pref-
erence to those people who are patients of the Native American
Health Center, and we have been very successful over the years.
Just last Saturday we awarded four scholarshipsnot big schol-
arships, $1,000 each, but we made those awards by raising funds.
We raised $7,000 by having the staff talent show, food sales
throughout the previous year. We felt it was important that we,
ourselves, award scholarships. We have two students going to jun-
ior college in the local area. One Indian student will be going to
Harvard this fall. So were very proud of what our community has
done in the area of not waiting for things to happen to us, but
being on the offense and doing things for our community.
 28

Last year our medical clinic saw over 4,800 patients, with over
16,800 visits. Of our patients, 98 percent meet the Federal poverty
level guidelines.
The services we provide reflect our communitys expanded defini-
tion of healththat health of an individual depends upon the
health of the community. If we have a healthy community, well
have healthy individuals within our community.
I would like to outline some of the critical issues facing our clin-
ics todayissues that ultimately impact the health of our commu-
nity in the Bay area.
Back in 1985 we bought a building in east Oakland, a four-story,
20,000-square-foot building. We bought that building at a time
when the market was very low. Today, we have filled up that build-
ingfour floors offering comprehensive services. Again, we also
have set up a fitness center, a gym on the first floor as part of our
preventive efforts.
The issues of providing health care has increased significantly
over the years. Pharmacy costs for us have increased by 34 percent
from fiscal year 1999 to fiscal year 2000. According to our medical
director, 20 percent of our medical users are diabetic20 percent
of our medical users are diabetic. A diabetic with high sugar, high
cholesterol, and high blood pressure, a very common combination,
can average $3,000 per year in drug costs. Just 40 such patients
for a clinic like ours can cost us $120,000 a year, or close to 13 per-
cent of the total IHS funding that we do receive.
Capital needs for our clinic have been and continue to be a major
issue for us. We have been located at 56 Julian Avenue since 1972.
We lost that lease this year. Our lease rent at the 56 Julian site
was $6,500 last year [sic]. We moved to a new location a 112blocks
down on Cap Street. Our rent has increased to $20,000 a year
a month. From $6,500 to $20,000 a month. The market has gone
up and exploded in the urban areas.
We are currently at full or near capacity in our medical clinics
and our dental clinics. Poor design, inefficient and inadequate tech-
nology has also been an issue that we have to struggle with. Weve
had to obtain additional funding from within private foundations
and corporations in order to buy the needed computer equipment
to at least continue to participate in the local health care delivery
system in Alameda County and in San Francisco.
Health insurance premiums for employeeswe have 120 employ-
ees. Our health insurance premiums have increased by 28 percent
in the last 3 years.
The California energy crisis is also having a major impact on us.
These costs have increased by 40 percent over previous years.
Another critical issue thats going to impact our ability to provide
primary care in the next year or two is something very positive in
our community. The Friendship House Association of American In-
dians will be building an 80-bed alcohol and drug treatment center
in San Francisco. Through a partnership with the city of San Fran-
cisco, they were able to obtain funding to buy property in the Mis-
sion District to build this 80-bed facility. That is great. There is a
need there. That 80-bed facility is going to become a regional treat-
ment center for not only California but for the western United
States.
 29

The Friendship House already has agreements with tribes in

California and throughout the western United States for those peo-
ple to come into the urban area to get their treatment for alcohol
and substance abuse. The problem for us is that we have to provide
the health care for them, and, as you know, those people that are
in recovery do need a lot of health care as they go about turning
their life around. How do I know that? Because 22 years ago I went
through the Friendship House. For 1 decade I was homeless on the
streets of Oakland and San Francisco. I entered the Friendship
House in 1980, March 12, 1980. This past year I celebrated another
year of sobriety. These urban programs do work.
A financial challenge for us is to find the funding and the financ-
ing to provide care for these people. When I went to the treatment
center in March 1980, I had to go next door to get my TB test and
also to get screened for my physical exam, and also my dental serv-
ices. I can always remember that, how they treated me there. After
coming off the streets of Oakland and San Francisco and coming
into the urban area, how they treated methey treated me as if
I was someone important. I was just 30 days into the program, into
the treatment, having gone through detox and going through the
first 30 days. My efforts today are just an attempt to repay back
what they gave me as an urban program 22 years ago.
The challenge for us in urban country, again, is the challenge
that we have to take on as urban Indian programs, is to build that
relationship with the tribes at the reservations. There has been
miscommunications, misunderstandings. We can get along individ-
ually, but somehow we dont get along as communities and groups.
We need to work on that. We are uniquely positioned in the State
of California, working with the California Rural Indian Health
Board, trying to put together their statewide HMO plan. It is a
unique opportunity for us in urban country to partner up with the
tribes and urban programs.
Many of our people do return. We are young. When the reloca-
tion programs took place in the 1960s and 1970s, we were a young
community. Those people in the urban areas were only in their
early twenties. Today, we are seeing more grandparents, more
grandfathers, grandmothers. We are seeing an elderly population
starting to emerge. Those of us who are in our fifties now are
grandmas and grandpas. What comes along with that is increased
cost, increased needs in our community.
Id like to thank you for the opportunity to give you my testi-
mony and appreciate all that this committee has done for Indian
people throughout the Nationmy relativesand we look forward
to improving the health care of our people together. We will work
on those things and we will do everything possible in the local
areas to help improve the future for the next generation.
Thank you.
The CHAIRMAN. I thank you very much, Mr. Waukazoo, for your
very inspiring statement.
[Prepared statement of Mr. Waukazoo appears in appendix]
The CHAIRMAN. May I now call upon Ms. Culbertson.
 30
STATEMENT OF KAY CULBERTSON, EXECUTIVE DIRECTOR,
DENVER INDIAN HEALTH AND FAMILY SERVICES, INC., DEN-
VER, CO
Ms. CULBERTSON. Good morning, Chairman Inouye and Vice
Chairman Campbell. Im very excited to be here, and I feel honored
because I wasnt supposed to be on the presenting committee, so
my testimony was very hurried.
My name is Kay Culbertson. I am an enrolled member of the
Fort Peck Assiniboine/Sioux Tribes from Poplar, MT, and today I
want to talk to you about Denver Indian Health and Family Serv-
ices. I think I am going to show you a different perspective of
urban Indian health than Mr. Waukazoo did. I didnt realize that
they had 100-some employees. I knew that they had a beautiful fa-
cility but didnt realize it was so large. So, as we say in Assini-
boine, Im going to give you the oonshaka story.
I want to talk about Denver. Like Oakland and San Francisco,
Denver was a relocation center for urban Indians or for Indians
moving off of the reservation. Theres also many Air Force bases
and military bases in the area, so a lot of people that moved to
Denver ended up staying there and raising their families there.
Like San Francisco and Oakland, we also see second- and third-
generation urban Indian people, but they still have their ties with
their reservation, and I would like to talk about that a little bit be-
cause my family is still very close to our people back home, and Im
very anxious to go back home tomorrow because our family will be
coming out of mourning on Saturday for my uncle that was killed
in an accident on the Northern Cheyenne Reservation and then my
grandmother that passed away last year.
One of the things that brought people to Denver was that hope
for a better future. Like all of the places, you know, we all thought
thatwell, my parents moved there when I was 6 years oldthat
wed improve our lives, that their children would grow up free from
racism and grow up in a better environment and have opportuni-
ties that they didnt have on the reservation.
I want to talk a little bit about Denver. Were located right in
the heart of Indian country. I mean, you fly into Denver, theres
conferences there all the time. Theres several national organiza-
tions with National Indian Health Board, Native American Rights
Fund, the American Indian College Fund, but as far as Indian
country goes were pretty isolated.
You talked about us being 250 miles away from the Southern
Ute Reservation. Thats true. And we dont see very many people
from Southern Ute. Its too beautiful to leave there, I think, and
to come to Denver. But we primarily see Lakota people, Sioux peo-
ple. Thats 60 percent of our population, and another 30 percent are
the Navajo people.
The closest Indian hospitals, like I said in my testimony, are in
Albuquerque and probably in Rapid City, so thats quite a long
haul for people to go if they need any kind of medical services that
we cant handle.
We were incorporated in 1978. We started out with two employ-
ees, and they were little ladies that worked in the community and
met with hospital people and when Indian people came to them
and needed help they helped them get into medical appointments
 31

or they helped them get to their medical appointment. They worked

with them to find dentists. It was a very sort of hodgepodge way
of providing services in the Denver area.
We started to grow. Actually, we were part of the Indian Center,
Denver Native Americans United, when we started, and we moved
away from the Indian Center and incorporated in 1978 as Denver
Indian Health Board, now known as Denver Indian Health and
Family Services. We had a full-scale clinic at one point with 21 em-
ployees, not to a point that Martys program was, but quite, quite
extensive for the Denver area. We had an agreement with the Den-
ver Health System to provide services, and, unfortunately, a lot of
the people that we see dont have health insurance. Of the popu-
lation that we see now, 70 percent dont have health insurance. Im
sure that it was as high or higher then, because there werent the
Medicaid programs and the CHIP programs that they have now.
And the people that were insured, the Indian people that came to
our clinic actually put a burden on our clinic and we ended up hav-
ing a huge debt with Denver Health and had to close our clinic op-
erations for the organization in 1991.
We then entered into a small agreement with a community
health clinic, but all along wed hear the community people say,
This isnt our community. Where is our clinic? We want our clinic
back. And so we started to work on that.
In 1998 our board had a planning retreat, and they decided that,
come hell or high water, we were going to have a clinic back in our
community, and so we started out really small. Very fortunately,
we found this young Indian doctor that was just so excited to be
providing services and was fresh out of medical school and wanted
to work for us, and she came and she helped us get our clinic li-
censed, so that was a big step for us. She could only work for us
20 hours a week. Unfortunately, her husband was also a doctor
andwell, fortunate for them, unfortunate for usand they ended
up moving to Billings, and we lost a fine doctor, a dedicated person,
so we had to backtrack and start to look at how we could continue
to provide services.
Eventually, we decided that we would go with the least-expen-
sive method of providing medical services for our community, and
that was through a nurse practitioner. We felt that a nurse practi-
tioner gave us what we neededa lot of health educationbut they
can do everything a doctor can do as long as they are supervised
by a doctor, except for surgery, of course, and so thats the mode
we are in now. We have a volunteer physician that oversees our
family nurse practitioner. We do well child checks, acute emer-
gencies, immunizations, womens health, and abuse physicalsany-
thing that you dont have to go to the hospital for specialty care
like x rays or casts or anything like that.
Let me talk about our community.
We serve people from Adams, Arapahoe, Boulder, Denver, Doug-
las, Jefferson, and Gilpin Counties. Thats a pretty large area, if
you look at Denver metropolitan area. But we do see people that
come from the reservations, particularly during March Pow-wow
you know, the things that are going on in the community we seem
to see a lot of people that come off the reservation, or if theyre vis-
iting their family. I cant tell you how many times people have
 32

come and needed prescriptions through our offices or need to get

something refilled because they forgot it at home or they ran out,
and so they come to us looking for those services.
Denvers population is fairly young. We have a median age of
30.2. A lot of older people dont stay in Denver, and I think it has
a lot to do with their health benefits and such that they move home
to the reservation because it is easier for them to receive services.
If they are fortunate to have health insurance, then theyll stay,
but we have a very small elderly population.
The annual income of a person that comes into our organization
is $7,452, and it is kind of crazy. We wonder why we have so many
people that arent on Medicaid or the other programs, but we real-
ize that they come to us thinking that they have a right to health
careas Indian people, they have a right to health care, and that
they should be able to go to any place and receive the services that
they would on the reservation.
Beyond our medical clinic, we also offer a community health pro-
gram that is sort of our hodgepodge of everything. It helps with
getting people prescriptions. We help pay for peoples prescriptions.
They also work very hard to sign up people on Medicaid and CHIP,
because one of the things we try to stress is that you cannot afford
to live in Denver if you do not have health insurance. One trip to
the hospital will wipe you out.
We have a new diabetes program, and wed like to thank you for
the additional funds. In addition to our management of glucose and
keeping an eye and making sure that our diabetics are keeping
their glucose levels in check, we are going to start offering new ex-
ercise programs and teaming up with different things in the com-
munity so that we have a more active community.
We also have a behavioral health program, and thats for mental
health and substance abuse counseling. Its a very small program.
We are in need of psychiatric backup for a lot of the things that
we provide.
We have Victims of Crime Act program, where we do case man-
agement, work very closely with the area victims programs.
Some of the challenges that Id like to talk to you about for Den-
ver Indian Healthand I see them as things that cant be over-
comeis that one of the things, unlike Martys program, is our
board has really struggled with is entertaining becoming a 330 pro-
gram or a Federally-qualified health center or a national health
service core provider because we dont want to lose our identity as
an Indian provider. Right now 99 percent of the people we see are
enrolled members of Federally-recognized tribes, and so we are
very proud of that, and we dont want to lose that. We dont want
to lose that complexion of our community.
We also see that part of it would include additional things that
we dont know we could handle, and that would be signing up with
an HMO and having 24-hour coverage and those type of things that
we havent been able to do now, so it really limits our ability in
third-party billing and we have a lot of work to go on there.
As we have said, IHS, as a whole, is funded very low, but urban
programs get the bottom of the barrel. One of the things that Id
like to mention that is very important to us is dental care. Theres
only one urban Indian health program that has funding for the
 33

dental program, and thats in Albuquerque, and thats just this

year that theyve received the funding.
We take 10 slots a month for emergency dental people, and weve
got a 3-month waiting list. I mean, I dont know how many people
can plan their emergencies for their dental visits, but it is very dif-
ficult. And alot of the providers in Denver dont accept Medicaid
patients, so were getting people that have the insurance but they
have nowhere to go, and that has been really hard.
A little boy was in my clinic the other day and we were looking
for a pedodontist to send him to because he was deathly afraid of
the dentist. We dont usually deal with children. We usually refer
them somewhere else. But they wouldnt accept him, either, be-
cause his family hadnt signed up for Medicaid. And so we were
looking, and I think they found a pedodontist the other day for
him, and hopefully his dental care is taken care of.
One of the problems we have is hiring and retaining qualified
professionals. Dr. Vanderwagen talked about 30 percent lower pay
rates for doctors or people that go into the tribal centers or into
IHS. We cant even begin to match the salaries that IHS provides
or the tribal facilities. I have calls from people calling about the di-
abetes positions that I have open, and theyre, like, Well, I cant
afford to move there. Id really like to move there, but you dont
pay enough. And its, like, Well, our budget doesnt allow for us
to be able to go much higher than this. And, unfortunately, were
not able to attract them because we dont have the benefits pack-
age that IHS has.
So yes, urban programs are eligible for the scholarship repay-
ment programs, but it is very limited because they really have to
take a much more decreased salary to come and work for an urban
program than they do with a tribe or with a IHS facility.
Ill go very quickly now.
Denver Indian Health and Family Services would like to support
the Indian Health Care Improvement Act. Weve testified on that
before, of our support.
Wed also like to support the elevation of the director of IHS to
Assistant Secretary for IHS. We think that through his innovation
well be able to access other grants through SAMHSA and different
programs other than IHS, and hopefully, with his speaking with
one voice theme for the Indian Health Care Improvement Act and
working with urban programs, that well begin to see urban pro-
grams included in some of the funding mechanisms. Right now a
lot of things are just for tribal programs or for tribal organizations.
Denver Indian Health and Family Services supports section 535
of the amendment to the Social Security Act to clarify that Indian
women with breast and cervical cancer who are eligible for health
services provided under a medical program of the IHS or a tribal
organization are included in the eligibility category of breast or cer-
vical cancer patients added by the Breast and Cervical Prevention
Treatment Act of 2000. Again, thats an example that the urban
programs will not be included in that and the urban Indians will
be left out.
Wed also like to support the demonstration projects. Weve heard
good things. We would like to see the report. But we think that
that is one way for programs that are isolated or that want to keep
 34

their identity as Indian providers to be able to go on and do that,

so we strongly support the funding of further demonstration
projects.
I want to close with a story. And I want to thank you for the op-
portunity to provide testimony today. As I was saying, I was work-
ing on my testimony last minute. My son is very active in the local
Native lacrosse program. Its a neat program. Theres about 25
families that participate in this program on a regular basis.
I was sitting there at the park with my laptop out typing and
working on this, and this mother that I have been friends with
through the year came up to me and said, Kay, what are you
working on? And I said, Well, Im working on some testimony.
And I didnt want to give her a lot of information because I didnt
really want to intimidate her in any way. And she said, Are you
an attorney? And I said, No. I said, Im the director of Denver
Indian Health, and she said, You are? And I said, Yeah. And
she said, What are you testifying on? I said, Urban Indian
health issues. And she said, I have a story for you.
Shes diabetic and she was pregnant with a set of twins and so
she was high-risk with her diabetes and also with a set of twins.
Her family had told her, Laura, go home. Go home and have your
babies on the reservation because then you wont have this huge
bill when you go out. Well, Laura didnt want to go home. She
wanted to have her children where she lived, and so she stayed in
Denver, without realizing what would happen. She had the babies.
I dont know what hospital she had them at. But they were in in-
tensive care for quite some time.
At the time they released her and her children, Laura left the
hospital with a $45,000 bill, and she told me, You know, we
couldnt afford it. We couldnt do it. But she said, I had to have
my babies. They needed this care.
So they ended up filing bankruptcy, and theyve never recovered.
Theyve never recovered from this. And Im sure that Laura is not
the only person in our community that has had those problems or
had to face that type of situation.
She asked me, she said, Will you tell my story? And I said,
Yes, I will.
I hope that in the future you will be able to give some answers
to people like Laura and provide us with additional funding for
urban programs.
Thank you.
The CHAIRMAN. I thank you very much, Ms. Culbertson. We will
try to help your friend.
[Prepared statement of Ms. Culbertson appears in appendix.]
The CHAIRMAN. Mr. Hall, what is your definition of an urban In-
dian health center? What services are they required to provide? Is
there any standard?
Mr. HALL. There are basically three levels currently existing,
with the highest being the comprehensive like Martys program,
where you provide a multitude of services. The second level would
be limited direct, much like Kays program, where you provide par-
tial services. And the third level is the outreach and referral, where
when people come to you for advice and how to find other services
that might be available.
 35

The CHAIRMAN. How many full-service clinics are there in urban

Indian health centers?
Mr. HALL. I think theres currently 14 that qualify for FQHC.
There are 10 limited direct service programs and ten outreach and
referral.
The CHAIRMAN. If I may ask the directors of the centers, how do
you determine your beneficiaries or your clients or your members?
Do they have to be enrolled members of tribes?
Ms. CULBERTSON. Every program is different. Denver Indian
Health and Family Services, because we dont have a State-recog-
nized tribe in Colorado, do not serve any State-recognized members
at this time.
When people come into our clinic, we ask them to bring their doc-
umentation either of tribal enrollment, or we will tell them, be-
cause theres so much inter-marriage in the urban areas, that they
are able to collect the CDIBs, and if they can come up with one-
quarter degree of Indian blood from the federally-recognized tribe
we will serve them.
But I know that everybody else has different
The CHAIRMAN. Does one have to have one-quarter blood quan-
tum?
Ms. CULBERTSON. Yes; and then we do get the people from tribes
such as the Cherokee where we get in 1/124th or something like
that, but we will serve regardless of blood quantum for tribal mem-
bers.
The CHAIRMAN. How is it done in Oakland?
Mr. WAUKAZOO. Self-identified.
The CHAIRMAN. What?
Mr. WAUKAZOO. Self-identified.
Ms. MEYERS. In Missoula they are enrolled member of the recog-
nized tribe or State, and are a descendent of an enrolled member.
If they can prove a descendence through the lineage, then we will
be able to provide services for them.
Mr. HUNTER. In New York City, Mr. Chairman, we use the defi-
nition as it is written in the Indian Health Care Improvement Act
in the current legislation, and that applies to our health services.
Our other programs have different requirements, but for our health
services we use that definition.
We were also able to convince the State, in its managed care
planning process, to accept that definition for exemptions to man-
datory managed care in the State.
The CHAIRMAN. Mr. Hall, how many individuals receive services
from these health centers?
Mr. HALL. In any one fiscal year it is approximately 100,000 Na-
tive Americans. If you compute that over a 3-year period, as we do
for the IHS user population, it averages about 175,000.
I would like to point out that, of those 14 comprehensive clinics,
weve only got two that are about the size of Martys. Most of us
are the size of mine, which is just under $1 million of total pro-
gram.
The CHAIRMAN. From your experience and from statistics that
you have gathered, what is the major health problem? Alcoholism?
Mr. HALL. Theyre very much similar with reservation. Diabetes
is a very high concern. In my program we service well over 500 dia-
 36

betics in our three urban clinics. Another high need, of course, is

alcohol program, alcohol treatment money. We have high incidence
of obesity and blood pressure problems. We have high incidence of
other related physical structure problems because of that.
The CHAIRMAN. Now, you have been here all morning and you
have listened to the testimony of the IHS. Are you satisfied with
your relationship with IHS?
Mr. HALL. Are you asking anybody in particular or all of us in
general?
Mr. WAUKAZOO. Could be better. Some of theno. No, we are
not. In some ways really dissatisfied with the formulas that they
use. Some of the formulas that they use for additional funding,
such as diabetes, was merely division. It doesnt take into account
service population. It doesnt take into account level of need. Divi-
sion. Diabetes funding that just came down was, as I understand
it, divided by the number of programs at two levels. So our center,
with two clinics, they treat us like one clinic. We have the overhead
at the San Francisco clinic, overhead costs in the East Bay, and
were treated as one clinic. If both of our clinics were stand-alone,
they would probably be within the top ten urban clinics in the Na-
tion largest. But the funding that comes down comes down based
on, from what I gather over my 20 years, division is the formula
being used.
Mr. HALL. There are a couple of other things, as was alluded to
earlier. There is direct service, IHS-provided service. Theres 638-
provided service by tribal groups who operate under the 638 au-
thority. And the authority that allows us as urban programs is the
buy-Indian authority. There are inconsistencies throughout IHS in
how we are treated through that buy-Indian authority, and were
trying to work as a national organization in making more uniform.
Were satisfied with a lot of our relationship with IHS and being
involved in consultation and having input into several of the poli-
cies, but it is still the bottom line. We are a very tiny portion of
the budget process. Were a very tiny voice in any consultation
issue, often one voice among up to 50, 60 representatives. And so
in the end, as you can see from the recommendations, our budgets
have been the last to be fully supported, and so weve got some con-
cerns about those kinds of things.
Theyre fixable. We have some concerns.
Mr. HUNTER. A lot of that also has to doand Ill refer back to
Dr. Vanderwagens testimony, in which he mentioned several times
that authority is not granted. They just dont have the authority
to do some of the things for urban programs that we need, and so
this is why certain parts of the Indian Health Care Improvement
Act are so important, because it will give the authority that we
need in order to partake of some of the services and available re-
sources that are out there.
Ms. CULBERTSON. It becomes a tenuous relationship. I dont
think that anybody is saying that they want to lose their relation-
ship with IHS, but I think that what wed like is some of the bene-
fits and the luxuries that tribes and IHS share in, such as the Fed-
eral Tort Claims Act. Were not eligible for that and so we have to
pay for malpractice when we become direct service providers. I
think thats one of the things we need to look at.
 37

Another thing is that they expect certain things from the urban
Indian health programs, and a lot of times they expect us to func-
tion like IHS facilities or tribal facilities with the limited funding
that we have. My operating budget is only about $400,000, so try-
ing to provide all the things that IHS provides, requires is some-
times overwhelming, and so I think that there needs to be some
sort of different look at how the urban programs can get their fund-
ing increased, get some of the benefits the tribes have, and also
provide some support for us.
The CHAIRMAN. Montana?
Ms. MEYERS. I would like to see a more workable relationship
with IHS. I grew up with IHS, and I would like to see, as an urban
settingand I put it on a personal note. Ive tried to convince my
parents to come live with me in Missoula, but because of the lim-
ited health coverage that they would receive in Missoula their
hands are tied. They would love to come and spend time with me
and live in an area that they enjoy, but because of the lack of cov-
erage of their medical needs it is totally impossible.
The CHAIRMAN. The first panel spent some time discussing tort
claims, malpractice. Is that a matter of major concern to the urban
Indian health centers?
Mr. HALL. If we fully participated under that protection, it would
save each one of us high malpractice insurance costs. We all have
to maintain high liability once we start providing direct service for
that. Again, its because of the authority. Because were not 638, it
doesnt apply to a buy-Indian provider, so technically right now, ac-
cording to what is legislated, we wouldnt be able to participate in
it. There would have to be some enabling legislation that would
allow us to be covered by that.
The CHAIRMAN. What is the cost of insurance in Denver?
Ms. CULBERTSON. Well, for us our insurance is running about
$800 a year, but we have a very good relationship with a nonprofit
group that provides the malpractice insurance for us. And because
we have such limited services, our malpractice insurance isnt as
high.
If we opened up our doors to OB, to prenatal care, our costs
would skyrocket and we wouldnt be able to afford those services.
So the malpractice really determines on what you offer, and
probably the best guess is Martys malpractice, because they are a
comprehensive center and are probably the closest to what an IHS
facility would be, how much their malpractice insurance costs.
The CHAIRMAN. How is it in Oakland?
Mr. WAUKAZOO. I dont have that figure in front of me right now.
The CHAIRMAN. Any figures from Montana?
Ms. MEYERS. Because we are a health outreach referral, we con-
sidered and looked at when we do become a clinicand thats one
of our goals, to become a clinic for our area. That is one issue that
has been discussed among staff and our board of directors is the
cost of malpractice insurance, which if we dont come under this
claim, the Tort Claims Act, then we will be looking at high insur-
ance in that area.
The CHAIRMAN. Anything in New York?
Mr. HUNTER. Very similar situation in New York, sir. We are an
outreach and referral. We do direct counseling services, and on oc-
 38

casion some of our counselors in the past have insisted that there
be coverage provided. We dont have it in our budgets, and so
theyve had to purchase their own malpractice insurance.
The CHAIRMAN. Mr. Hunter, I would gather that most of your
beneficiaries are from outside New York?
Mr. HUNTER. Yes; a large segment of the population is Mohawk
from the two reservations in upstate New York. A large population
is from eastern Long Island from Shinnecock and the Unkechaug
Reservation. Shinnecock is about 90 miles east. Thats where my
family is. And Cherokee people are also a large number. In our De-
partment of Labor statistics, I just noticed in reviewing those that
Navajo is also well represented in New York City.
The CHAIRMAN. And for Montana the population is from that
area?
Ms. MEYERS. The biggest population that we serve are the Black-
feet, and it goes on down to the Flathead, which is Salish and
Kootenai, Asinniboine. All the 11 tribes that live in the State of
Montana do come to the Missoula area, plus nationwide we have
Navajos from the southwest, Apache that do come up to attend the
University of Montana, and we have a variety.
The CHAIRMAN. How is it in Oakland?
Mr. WAUKAZOO. The largest group of tribes that we provide serv-
ice for are the California tribes. Individually largest group is the
Navajo, Lakota, Pomo, Cherokee, Apache, Paiute, Blackfeet, Choc-
taw, and Chippewa, in that order.
The CHAIRMAN. Denver?
Ms. CULBERTSON. Well, as I said before, 64 percent of the people
we see are from the Sioux tribes, and then 30 percent are Navajo,
and then it is a whole mixture. The one tribe we rarely, rarely see
are the Southern Utes and the people from our home State.
The CHAIRMAN. Well, I thank you.
May I now call upon the vice chairman.
Senator CAMPBELL. Thank you, Mr. Chairman. We have a con-
ference in another 15 minutes or so, so Im going to submit most
of my questions in writing, if thats acceptable.
I might just ask Kay, does Rosalie Tall Bull work with you?
Ms. CULBERTSON. No; Gloria works for me. Shes my community
health specialist. But Rosalie works for National Indian Health
Board.
Senator CAMPBELL. Okay. Shes my sister. I dont know if you
knew that.
Ms. CULBERTSON. Yes; I knew.
Senator CAMPBELL. Tell her hello for me. You see her more than
I do.
Ms. CULBERTSON. Ive got alot of friends that know you.
Senator CAMPBELL. Yes; alot of relatives.
Carol, does Henrietta Whiteman still run the Native American
studies program up there at Missoula?
Ms. MEYERS. No; unfortunately, Bozeman got her.
Senator CAMPBELL. Bozeman? Oh.
Ms. MEYERS. And so shes down in the Bozeman area at MSU.
Senator CAMPBELL. I see. Well, shes not my sister. Shes my
cousin.
Ms. MEYERS. Okay. Thats good.
 39

Senator CAMPBELL. You can tell her hello if you see her, too. I
dont have any relatives in anybody elses area thats testifying, but
they brought up some really interesting questions, Mr. Chairman.
Im probably not going to get into them. We just wont have the
time.
But Mr. Waukazoo really I thought alluded to something really
important, and that is that when you talk about Indian healing its
just not a matter of giving them pills and Band-Aids. Its a form
of holistic healing. So much of Indian healing has to do with their
spiritual feeling and their cultural feeling about being in balance
with their surroundings and so on.
I think that when you talk about all the activities you have in
your center, your health center, and Mr. Hunters too, in New York,
superficially you might say, Well, what do those have to do with
health? But they have a lot to do with health with Indians, and
I think they are really worth pursuing and worth expanding, too,
if you can do this.
Obviously theres a question of how to finance all those things,
and thats what I wanted to ask you. You must have a pretty large
staff to do all those different activities you do. Is that all done with
donations and volunteerism?
Mr. WAUKAZOO. Its done with a lot of dedication and commit-
ment on the part of the staff. And I agree with you 100 percent
about health careits much more than just providing health care
externally in the western model.
You know, when I was growing up in South Dakota my parents
used to tell me, Get out of the house. Go out and play. Today par-
ents are saying, Stay in the house.
Senator CAMPBELL. Yes; youll get sick.
Mr. WAUKAZOO. Dont go outside. So now we have a generation
who is growing up. I coach the Grasshoppers. We have a tribal ath-
letic program, part of our clinic. The Grasshoppers are first and
second graders, little guys. I coach them. We havent won a game
in 2 years, but thats not important. [Laughter.]
Senator CAMPBELL. Youre developing character.
Mr. WAUKAZOO. Whats very important is that theyre out there
getting active and theyre learning that theyre at risk for diabetes.
But they cant even run up and down the court three or four times
without getting tired. We get ahead by two or three points at the
end of the first quarter but we loose by the end of the game be-
cause theyre all tired.
How do we do it with financing? Well, health care is local. We
spend a lot of time and a lot of energy at the local level. The local
level and the State and the county delivery system have a respon-
sibility also.
Our greatest concern is were seeing a larger and larger group of
those uninsured, those individuals that are not eligible for Medi-
care, Medicaid, Medical in our State.
Then we also look in that other option in partnering up with dif-
ferent other organizations. We will be building a youth develop-
ment center in the next year which will incorporate a gymnasium,
performing arts studio, fitness center, and its really about the next
generation because thats our largest population. If we can get in
front of this diabetes and these other health problems, you know,
 40

instead of trying to pull them out of the stream, go upriver and

build or repair that bridge to keep them from falling into that.
Thats the initiative that weve taken.
Were quite proud of the fact that our physicians both have been
with us for over 18 years. Our dentist has been with us for 25
years. My assistant director has been with me for 16 years.
Senator CAMPBELL. Thats a commitment.
Mr. WAUKAZOO. And, following my fathers advice 20 years ago
when I took this job, he said, The best place to be when you dont
know anything is in charge. [Laughter.]
Senator CAMPBELL. Thats why were here. [Laughter.]
Mr. Chairman, years ago I asked an old man who was a half-
brother to my grandmother, I went over to visit him one time and
he had a really bad cold and I asked him why Indian people have
such health problems now that they didnt have in the olden days,
and he gave me an interesting answer. He said, Because look
what were living in. I dont remember the exact words, it has
been so many years ago, but he pointed out in the olden times In-
dian people lived with nature. In the case of the Plains people, all
of their structures were round. The sweat lodge, the tepee, and so
on, were all round to reflect the circle of nature, the circle of life.
And he said that when they were moved into square houses it was
kind of an affront to the natural way of living and he thought that
their health problems went up when that lifestyle changed and liv-
ing in square things instead of round things.
As I began to reflect on that, almost all Indian housing, whether
it was the Plains tribes or the Southwest tribes in the desert or no
matter where, the northeast, their structures were round. Maybe
he knew something we didnt know. But thats what his belief
waskind of an old-time belief about why health problems go up
if youre out of tune with nature.
Mr. Hall, I remember we had the infamous tobacco settlement
debate here a few years ago and this committee certainly went to
bat for the Indian tribes being included in that tobacco settlement.
In fact, the current Secretary of the Interior came back and testi-
fied. She was the attorney general for Colorado then. She testified
to help us make sure there were Indian provisions in that settle-
ment.
The thing fell apart because, typical of the Senate, we went off
in 100 different directions and we couldnt get anything passed.
But States did, as you know, go ahead and sue tobacco companies
and reached some settlements.
Do urban Indian centers have access to any of the settlement
funds that went into States? Do you know?
Mr. HALL. That varies by St. Montana I know gets a little bit per
each urban center. In South Dakota we got zip.
Senator CAMPBELL. You got zip.
Mr. HALL. All of South Dakotas money went to tax relief. Cali-
forniaI believe you guys participated in that a little bit. But it
varied by State.
Senator CAMPBELL. State by State. There was no negotiated
agreement with the States and tribes.
Another question, Mr. Hall. Some Indian centers access commu-
nity health center funding. Denver does not, I understand. Is the
 41

reason because you would have to accept anyone? Oakland does, I

guess. You would have to accept anyone, regardless of whether
they were Indian or not if you accept those funds?
Mr. HALL. A little bit of it is that reason. The other part of it
is that those clinics pretty much operate as a clinic in a dominant
society. Where the access is is from our people feeling uncomfort-
able in those kind of environments. For example, in the State of
South Dakota the family planning office has made three major ef-
forts to reach Native American women in the past 10 years. This
July 1 they finally contracted with us for a very small contract to
reach out to Native American women, and in the past 10 years
they havent increased their numbers at all, and weve already sub-
mitted 25 names in less than 1 month. So its a matter of where
Indian people feel comfortable getting their service.
Its not just a matter of their being resistant. We have to under-
stand this whole cultural history of being Indian in this country is
like being an outsider in any environment, especially when you get
up in places like South Dakota. So its not just that, its also the
recognition that Indian health care is a Federal responsibility, so
many State offices and stuff are not inviting to Indian people.
Another part of the issue is it is run very much in a time con-
strained manner. If youre late with an appointment, just like with
TANF, you end up getting on sanctions, and when you dont have
gas for the car or your babysitter is not there, boomadee,
boomadee, boomadee, youre late. And so people get very reluctant
to do that, just like a lot of our people that qualify for Medicaid.
We have to push and push and push to get them to jump through
the hoops of applying for it because of a perception and in many
instances the reality of being discriminated against in that applica-
tion process.
So when you take a full look at how our people have bumped into
walls getting service in various dominant society options, it really
ends up being no option.
Senator CAMPBELL. Sure.
Mr. HALL. In Sioux Falls, for example, Ive had several OB/GYN
people tell us that they see a young lady or a young woman when
she finds out shes pregnant and again when she calls in the emer-
gency room having a baby because of that limited sense of comfort
with the dominant societys provisions.
Senator CAMPBELL. I understand that.
Mr. HALL. Sorry for the long answer, but it was
Senator CAMPBELL. No; thats all right. I appreciate it.
Mr. Waukazoo, as I understand it, youwhat did you say? The
people that come into the clinic self identify? Is that the word you
used?
Mr. WAUKAZOO. Yes.
Senator CAMPBELL. That means if they come in and they say,
Im Indian and I need help, you go ahead and help them?
Mr. WAUKAZOO. Yes.
Senator CAMPBELL. You dont ask them for an enrollment num-
ber or anything?
Mr. WAUKAZOO. No; they self identify as American Indians.
Senator CAMPBELL. Dealing with health service, then, how do
you handle a mixed family? A guy comes in and says, Im Indian.
 42

His wife says, Im not. And theyve got a couple of kids with
them. Do you say, Well, we can help you but not her? How do
you deal with that?
Mr. WAUKAZOO. Thats whats in the family.
Senator CAMPBELL. Okay. So if he identifies, his whole family
then is
Mr. WAUKAZOO. Yes; the communityyou know, in the Bay
areain urban areas the community is spread out but it is very
highly connected. Its well known. Its just like on the reservation.
You know who is on the reservation.
Senator CAMPBELL. You generally know because youve seen
them at activities
Mr. WAUKAZOO. Yes.
Senator CAMPBELL [continuing]. And they participate in the com-
munity.
Mr. WAUKAZOO. Yes; right.
Senator CAMPBELL. I see.
Mr. WAUKAZOO. And that decision generally is within the family
as far as where the health care is going to be taken care of, so we
dont get into that part of it.
Senator CAMPBELL. I see.
I think, in the essence of time, Mr. Chairman, Ill submit the rest
of my questions in writing, if I could ask the panel to respond.
Thank you, Mr. Chairman.
The CHAIRMAN. I will also join you in submitting questions, if I
may.
A final question. In the Native Hawaiian Health Improvement
Act, there is a provision for traditional Native healers and tradi-
tional Native Hawaiian healers are officially recognized by the Gov-
ernment of the United States. They are compensated for their serv-
ices.
Are Native American Indians interested in having this act pro-
vide for traditional Native healers? I do not want to tell you what
to do, because I believe in you telling us what to do.
Mr. HALL. I just came from the Aberdeen Area Tribal Chairmans
Health Board meeting, where they spoke of this very issue. They
had a healer from the Navajo Reservation that is part of the
Shiprock, I believeno, excuse me, Winslow service unit. Some of
the requirements you have to go through to become billable under
Medicaid are so stringent that most of the healers feel they are
stepping outside of their cultural powers to participate in that, so
most of them, as it is now structured, are not reimbursable.
From the conversation of the Navajo people and from the Lakota
people and others up in the Aberdeen area, if that provision youre
describing could be applied without having to do all of the hoops,
theyd very much appreciate it.
IHS, as a whole, is being very receptive to utilizing traditional
healers, and I think the tribes, but we dont all speak for the tribes.
I can only speak from that experience.
The CHAIRMAN. Any objections?
Mr. WAUKAZOO. I would just say that it would be a decision that
I would prefer to have the tribes make, and if the decision is yes,
then we would be very supportive. But, you know, sometimes we
have to, in urban programs, kind of step back and follow the tribes.
 43

The CHAIRMAN. I think your position is correct. We will most cer-

tainly discuss this matter with tribal leaders.
Before we adjourn, I would like to note the presence of Dr.
Vanderwagen. He has been sitting here all morning, and if you
have been to Senate hearings you will note that Government wit-
nesses oftentimes testify and leave immediately, but he has been
here and listening to your testimony, and I think all of us owe him
a great debt of gratitude. I commend you, sir, for doing that.
[Applause.]
The CHAIRMAN. He was good enough to sit here to listen to your
concerns, if you had any.
With that, I thank you all for patiently waiting. Your testimony
is very much appreciated. It has been inspiring and moving.
Thank you.
[Whereupon, at 12:20 p.m., the committee was adjourned, to re-
convene at the call of the Chair.]
 APPENDIX

ADDITIONAL MATERIAL SUBMITTED FOR THE RECORD

PREPARED STATEMENT OF HON. KENT CONRAD, U.S. SENATOR FROM NORTH DAKOTA
Mr. Chairman, thank you for holding todays hearing on the personnel and urban
Indian provisions of the Indian Health Care Improvement Act.
Senator Dorgan and I chaired a field hearing last August in North Dakota to con-
sider this legislation. I can attest to the fact that tribes in my State believe changes
need to be made to the way health care is delivered throughout Indian country.
This bill is one of the most important pieces of legislation being considered by this
committee. Tribes in North Dakota have told me time and again that health care
is their top priority. Without healthy people, all other endeavors will be less success-
ful.
I am pleased that the committee has worked so closely with tribes in putting to-
gether this important bill. I hope we are nearly to the point where we can pass this
legislation and allow health care improvements to move forward throughout Indian
country.
This is especially important for the growing number of young Native Americans.
We need a greater emphasis on prevention of disease and injury overall, but espe-
cially with respect to young people. Wellness and nutrition training, teaching young
people to stay away from drugs, tobacco, and alcohol, and greater attention to the
mental well-being of young people are all goals that I believe we should embrace.
Greater access to medical care, both rural and urban, and more health care person-
nel throughout the system are vital to reaching those goals.
Mr. Chairman, thank you for holding this hearing today.

PREPARED STATEMENT OF HON. TOM DASCHLE, U.S. SENATOR FROM SOUTH DAKOTA
Mr. Chairman, thank you for the opportunity to testify on one of the most impor-
tant issues before this committeeour commitment to provide quality health care
for American Indians and Alaska Natives. As you know, the Indian Health Service
[IHS] is in far too many cases unable to provide even basic health services to Amer-
ican Indians and Alaska Natives. We are failing to uphold a promise we made many
years ago in Federal-tribal treaties as well as Federal statute.
The IHS is tasked with providing full health coverage and care for American Indi-
ans and Alaska Natives, but is so underfunded that patients are routinely denied
care that most of us take for granted and, in many cases, call essential. The budget
for clinical services is so inadequate that Indian patients are frequently subjected
to a life or limb test. Unless their condition is life-threatening or they risk losing
a limb, their treatment is deferred for higher priority cases; by the time they become
a priority, there are often no funds left to pay for the treatment.
As devastating as the problem is for Native American patients and the tribal gov-
ernments struggling to address their peoples health needs, the problem does not
end there. IHS often contracts with non-IHS facilities to provide care that cannot
be provided at local IHS clinics and hospitals, due either to the complicated nature
(45)
 46
of the needed service or a lack of funds. These non-IHS facilities often receive no
reimbursement for the services they provide and, as a result, face serious budget
shortfalls of their own. In 1999 alone, IHS issued 20,000 contract health service de-
nials, leaving the contract facilities without any reimbursement.
A compelling example of the impact of this underfunding is the inability of many
tribes to provide emergency medical services [EMS] to their residents. IHS uses its
authority through the Indian Self-Determination and Education Assistance Act of
1975 to contract EMS to tribes. Throughout Indian country, however, ambulance
service is funded at only 47 percent of the determined need. On the Rosebud Res-
ervation in South Dakota, the funding for EMS is depleted by mid-year. The Rose-
bud Sioux Tribes EMS contractors respond to 425 calls per month. The local IHS
facility does not have an obstetrical or surgical unit, so all high-risk pregnancies
and surgeries have to be transferred by the EMS providers to private hospitals lo-
cated 180 to 260 miles from the reservation. When the tribes funds for EMS are
depleted, other local providers are often called to respond to emergency transport
needs. Consequently, local EMS providers experience serious financial difficulties
because there are no funds left to reimburse them. Ultimately, this situation can
result in discontinuation of ambulance services in a rural area.
I attempted to address the crisis created by this serious, chronic underfunding of
IHS by offering an amendment to the fiscal year 2002 budget resolution. The
amendment called for a $4.2-billion increase for the fiscal year 2002 clinical services
budget of the IHS. This amendment passed the Senate, but was not included in the
bill that returned from conference. I again attempted to address this situation in
the Interior Appropriations bill, but it appears that we will be unable to do that
at this time due to the inadequate budget allocation facing the Interior Appropria-
tions Subcommittee.
It seems Congress has grown so accustomed to inadequate IHS funding that we
are failing to recognize the extraordinary tragedy tribal people are facing. The prob-
lem seems so big that we are almost afraid to tackle it. But we cannot afford to
shirk our responsibility.
One reason the problem seems so intractable is that IHS fundingand, in turn,
health care for Native Americansdepends on the vicissitudes of the appropriations
process. The budget for IHS has been so underfunded for so long, our annual appro-
priations process may never allow us to increase it enough to adequately address
the health needs of American Indians and Alaska Natives. The magnitude of the
increase I requested is evidence of this point: For fiscal year 2002, I requested a
$4.2-billion increase to the $1.8 billion budgeted for IHS clinical services. This 233
percent increase is based on two conservative estimates of the amount needed to
adequately fund the provision of basic clinical services: The tribal needs budget and
the level of need funding budget, developed by the tribes and IHS respectively.
It is time to change the way we fund our commitment to provide health services
to American Indians and Alaska Natives. This Federal responsibility was codified
by treaties and laws dating from 1787 and required under the trust responsibility
of the United States to the tribes. It is clear that, in a historic and moral context,
American Indians and Alaska Natives are entitled to receive adequate health serv-
ices from the Federal Government. Why then, are they not getting it?
What some may not know is that health care for Indians is not delivered as an
entitlement. I have come to believe it is time to consider changing the funding
mechanism for IHS from a domestic discretionary program to an entitlement. Un-
less we can demonstrate a renewed commitment to Indian health care in the budget
and appropriations process, granting entitlement status may be the only way we
will live up to our obligation. I understand the political challenges that this entails.
For Indian people, however, this is not a. question of politics. It is a question of his-
tory and obligation. It is a question of health and life.
If Indian health were moved from a domestic discretionary program to an entitle-
ment program, it would no longer shoulder the burden of balancing the Nations
budget, along with other discretionary programs. We would have to develop a new
process to quantify Indian health based on services and beneficiaries. Funding
would be guaranteed.
I wholeheartedly support, therefore, the provision in the Indian Health Care Im-
provement Act which establishes a National Bipartisan Commission on Indian
Health Care Entitlement. I look forward to the Commissions report, and to continu-
ing the discussion of this critical issue.
I would like to bring to your attention another critical issue impacting IHSs abil-
ity to provide health care services. The IHS experiences enormous difficulties in re-
cruiting and retaining health professionals. In 1999, in the Sisseton Indian Health
Service unit, there were 34 different physicians providing medical care in four fund-
ed provider positions. This high turnover rate significantly erodes the IHSs ability
 47
to provide high quality health care services and continuity of care. We must address
this issue because, without health care professionals, health care services cannot be
delivered.
The Sicangu Sioux on the Rosebud Indian Reservation in South Dakota recently
built a beautiful new hospital and health care center. While in many ways they are
equipped to provide state-of-the-art care, they are unable to retain health care pro-
fessionals. As a result, their brand new delivery and surgery rooms stand empty,
and individuals living on the reservation are forced to travel long distances to re-
ceive these vital services.
There are many documented reasons for the difficulty recruiting and retaining
IHS health professionals, including low pay, lack of suitable housing, isolation, and
an overwhelming workload. Some health care professionals do not want to practice
long-term in chronically underfunded, crowded and outdated facilities that lack es-
sential equipment. I am pleased that S. 212 includes an array of excellent programs
to improve the ability of the IHS to recruit and retain health care professionals.
There is, however, one issue that is not addressed in S. 212: Medical license reci-
procity for HIS physicians.
IHS physicians, as a condition of employment, must hold a license in at lease one
State. Since they are Federal employees, this license should guarantee their ability
to work as an IHS physician in any State. This concept is called reciprocity. In
South Dakota, IHS physicians are granted reciprocity and allowed to practice under
a license issued from a different State. Their scope of practice, however, is limited;
they are not allowed to practice outside of an IHS facility. This limitation is ex-
tremely frustrating, since, due to severe underfunding of the IHS, many areas do
not have IHS facilities, such as hospitals, nursing homes, or specialized clinics.
Many physicians prefer to follow their patients throughout the systems of care. If
an IHS patient is transferred from an IHS facility to a non-IHS facility for inpatient
care, for example, the IHS physician is currently forced to turn over the care to a
non-IHS physician, who may not even know the patient.
Given the many challenges IHS faces in recruiting physicians, I firmly believe we
should not create another barrier. The inability of IHS physicians to practice outside
the bricks and mortar of an IHS facility has led to the resignation of too many IHS
physicians. I hope we can find a way to remove this barrier as we move forward
with S. 212.
I was pleased to see that S. 212 continues an emphasis on programs to com-
prehensively address substance abuse and Fetal Alcohol Syndrome [FAS]. According
to IHS, the 199495 age adjusted death rate for alcoholism in the IHS Service Area
was more than six times that of the general population. Yet, treatment services for
Native Americans remain severely inadequate.
Programs to address FAS are particularly crucial. FAS is the leading preventable
cause of mental retardation in the United States and the No. 1 cause of preventable
birth defects. Although the exact prevalence of this disorder is unknown, studies
have estimated that 3 out of 1,000 Native American children are born with FAS,
and many more with less severe alcohol-related impairments.
These statistics highlight the urgent need for increased access to residential treat-
ment services for women of childbearing age. In the Pine Ridge area of South Da-
kota, there is currently a five-month wait for IHS residential substance abuse treat-
ment programs. This means that if an alcoholic woman learns she is pregnant and
is motivated enough to request treatment, she would probably be more than 6
months into her pregnancy before a bed was available. By this time, her unborn
child could be severely and permanently damaged.
We need to ensure that when a pregnant woman walks in the door to ask for help
with her drinking, help is available. In addition, we need to do all we can to educate
Native American women, as well as professionals who serve the Native American
community [as well as the non-Native community], about FAS and the dangers of
drinking while pregnant. And we need to ensure that when these approaches have
failed and a child is born with FAS, that child has access to the medical, edu-
cational, and social services he or she needs.
In closing, I would like to thank the chairman, the vice chairman and the entire
committee for their dedication to improving the health of American Indians and
Alaska Natives. S. 212 is a comprehensive reauthorization of the Indian Health
Care Improvement Act, and, when enacted and if adequately funded, will go a long
way toward reducing the disparities in health outcomes between Native and other
Americans. It saddens me to know that the mortality rate for American Indians and
Alaska Natives is higher than for all races in the United States, and life expectancy
is the lowest. I commend you for your efforts to eliminate these disparities and live
up to our commitment to provide health services to American Indians and Alaska
Natives.
 48
PREPARED STATEMENT OF DR. WILLIAM C. VANDERWAGEN, ACTING CHIEF MEDICAL
OFFICER, INDIAN HEALTH SERVICE, DEPARTMENT OF HEALTH AND HUMAN SERVICES
Good morning, Mr. Chairman and members of the committee. I am Dr. William
C. Vanderwagen, acting chief medical officer, Indian Health Service [IHS], Depart-
ment of Health and Human Services.
I am pleased to be here this morning to testify before the Senate Indian Affairs
Committee about two important areas within the IHS service responsibilities.
The first issue of health manpower, providing and retaining sufficient health pro-
fessionals for our health care delivery system, is one shared by the country overall.
The second matter concerns the operation and challenges facing the urban Indian
health programs.
In meeting our goals, the IHS has adhered to its policy of working with our tribal
and urban partners and constituents, on key decisions and actions. Efforts to im-
prove program delivery of services are greatly improved by such consultation and
cooperation.
The IHS health care delivery system is comprised of 49 hospitals, 219 health cen-
ters, 7 school health centers and 293 health stations. The American Indian and
Alaska Native eligible population, in fiscal year 2000 was approximately 1.51 mil-
lion. This service population is increasing at a rate of about 23 percent per year,
and this estimate excludes the effect of the additions of new tribes. *[Trends 1998
99]
Patient admissions into our IRS, tribal and contract general hospitals, in fiscal
year 1997, were about 85,000. Main causes for admission were births and pregnancy
complications. The 2 ambulatory statistics in fiscal year 1997 show over 7.3 million
medical visits provided through the IHS-funded operations.
There, are additional data to be found in our IHS 199899 Trends publication,
but the main purpose of this review is to provide the backdrop against which much
of our discussions will take place this morning.
It is to the credit of our personnel, health professionals and others, that all of our
IHS and tribally operated health facilities had achieved accreditation by the Joint
Commission on Accreditation of Health Care, Organizations [JCAHCO]. This rating
was true as of January 20, 1999.
To fulfill our primary goal of ensuring that we achieve the highest possible health
status among American Indians and Alaska Natives, the health professions activi-
ties are critical but could be tested over the next 5 years. The IHS could lose a sub-
stantial number of its staff for a variety of reasons, including age-eligible retirement
and the fulfillment of service obligations.
As of the end of June 2001, nearly 22 percent of our 13,000 Federal employees,
throughout the whole system, had 20 or more years of service. Within the health
professions, 18 percent of the 8,600 health-related employees in the 600 personnel
series, in which most of the health professionals are found, are in the 20-plus years
category. Finally, of the three most numerous health professions, nurses, phar-
macists, and dentists, all of these groups have more than 12 percent of their staffs
in this group age-eligible retirement category. Physicians have 8 percent of all of
our IHS physicians are in the 20-plus years category.
Our plans for addressing this pending situation include the institution of even
more vigorous recruitment efforts and a greatly increased emphasis on retention.
Such activities include:
1. Increased advertising in professional journals.
2. Increased Health Educational Institution Recruitment Visits.
3. Increased web-based Advertising.
Retention has been a major factor in reaching our current status. The average
length of service for all IHS employees is just over 12 years. For those in the 600
series, it is just over 11 years.
Of our four most numerous professions, nurses have the longest average length
of service, at nearly 11 years. Physicians, with 8 years, have the shortest, while den-
tists and pharmacists average just over 9 years each. The difficulty, however, is that
we lose many of our new recruits before they have served 5 years. Therefore, reten-
tion of new employees must remain a priority.
These difficulties in retention include culture and transition issues, within rural
and often disadvantaged communities. Additionally, the competition for such quali-
fied individuals is huge. Many of these professionals are often approached by other
health care institutions with more attractive employee benefits packages and place-
ments. This situation, of competing health care systems, is only going to grow in
future years as our population, national and in Indian communities continue to live
longer and more productive lives.
 49
Our scholarship and loan repayment programs offer us the opportunity to attract
highly qualified staff. In fiscal year 2000, 37 new scholarships were awarded to par-
ticipants in two undergraduate scholarship programs in the Health Professions with
46 extensions. Forty-five new awards were made in the Preparatory Pregraduate
scholarship program with 61 extensions, and 60 new awards were made to students
in a health professions graduate programs with 287 extensions.
In fiscal year 1996, the average debt load of a new loan repayment program par-
ticipant was S32,000. In fiscal year 2000, it was $64,000. We anticipate that this
individual debt load will be even higher this year.
Such educational financial assistance, in turn, assures the IHS of a service com-
mitment by the individual who receives such aid. Service payback commitment
can range from 2 to 4 years. Once such commitment is completed, an individual may
have private practice goals or family obligations that preclude their further employ-
ment within the Indian health care system.
Today 62.3 percent of all American Indians and Alaska Natives identified in the
1990 Census reside off-reservation. This figure represents 1.39 million of the 2.24
million American Indian/Alaska Natives identified in the 1990 Census updated by
Indian Health Service. The updated 1994 Census identifies 1.3 million [58 percent]
of the American Indian/Alaska Natives residing in urban areas. For comparison pur-
poses the Indian Health Service total service population is 1.4 million with active
users at 1.2 million. This figure includes 427,100 eligible urban Indian active users
who reside in geographic locations with access to an Indian Health Service or Tribal
facility.
In 1976 Congress passed the Indian Health Care Improvement Act [IHCIA] [Pub-
lic Law 94437]. Title V of the [IHCIA] targeted specific funding for the develop-
ment of supporting health programs for American Indians/Alaska Natives residing
in urban areas. Since passage of this landmark legislation, amendments to title V
have strengthened Urban Indian Health programs [UIHPs] to expand to direct med-
ical services, alcohol services, mental health services, HIV services, and health pro-
motion and disease prevention services. [Public Law 100713, Public Law 101630,
Public Law 102573].
The UIHPs consist of 34 nonprofit 501 (C)(3) programs nationwide funded through
grants and contracts from the Indian Health Service, under title V of IHCIA, Public
Law 94437, as amended. Sixteen [16] of the 34 programs receive Medicaid reim-
bursement as Federally Qualified Health Centers [FQHCs) and others receive fee
for service under Medicaid for allowable services, that is, behavioral services, trans-
portation, et cetera. The other programs are automatically eligible by law but may
not provide all of the necessary primary care service requirements mandated by
FQHC legislation. Over $10 million are generated in other revenue sources.
In the Omnibus Budget Reconciliation Act [OBRA] of 1993, title V of the IHCIA,
and tribal 638 self-governance programs were added to the list of specific programs
automatically eligible as FQHCs. The range of contract and grant funded programs
below are provided in facilities owned or leased by the Urban organizations. Pursu-
ant to title V, the Indian Health Service is required by law to conduct an annual
program review using various-programs standards of Indian Health Service and to
provide technical assistance to the Urban Indian Health Programs.
The range of Indian Health Service/Urban grant and contract programs services
can include: Information, outreach and referral, dental services, comprehensive pri-
mary care services, limited primary care services, community health, substance
abuse [outpatient and inpatient services], behavioral health services, immuniza-
tions, HIV activities, Health Promotion and Disease prevention, and other health
programs funded through other State and Federal, and local resources, for example,
WIC, Social Services, Medicaid, Maternal Child Health.
Sixteen [16] of the 34 programs are certified as Federally Qualified Health Cen-
ters. The other programs are automatically eligible by law but may not provide all
of the necessary primary care service requirements mandated by FQHC legislation.
Today the Indian Health Service provides funding to the 36 [34 title V of the
lHCIA and two demonstration programs] urban Indian health centers and to 10
urban Indian alcohol programs. The urban Indian health programs, range from com-
prehensive primary care centers to referral and information stations. In fiscal year
2001 Congress appropriated $29,843 million for Urban Indian Health. These centers
continue to receive funding as well, from a variety of other Federal, state and pri-
vate sources.
Mr. Chairman, this concludes my prepared statement, I will be happy to respond
to any questions you and other committee members may have.
 50
PREPARED STATEMENT OF MICHAEL E. BIRD, PRESIDENT, AMERICAN PUBLIC HEALTH
ASSOCIATION
Mr. Chairman and members of the committee, I am Michael Bird, president of
the American Public Health Association. However, today, I am representing the
Friends of Indian Health, a coalition of over 40 health organizations and individ-
uals. The Friends were formed in 1997 to improve the funding and delivery of
health services to American Indians and Alaska Natives [AVAN].
We thank you for the opportunity to testify today and to comment on health care
personnel issues that we think could be addressed in the Reauthorization of the In-
dian Health Care Improvement Act, S. 212. While the individual members of the
Friends have profession specific concerns we are united on the need to improve the
recruitment and retention of health care providers in the IHS.
A member of the Friends recently sought care from the Phoenix Indian Medical
Center [PIMC]. For a 1 oclock doctors appointment, he left his home at 11 a.m.,
arriving at the PIMC at noon. Having been there before, he knew that he needed
to arrive an hour before his appointment because patients are seen on a first come,
first serve basis . . . even though he had a scheduled appointment. At this facility,
the patient to doctor ratio is overwhelming. Not only does it serve Indian patients
from the Phoenix city limits but also patients from the adjacent reservations that
do not have inpatient services are brought in by vans. The patient was eventually
seen but also told that his back condition had worsened and would probably need
surgery for several herniated discs. However, because of a lack of orthopedists at
the PIMC he was unable to schedule a consultation until September 27. The pa-
tients check up took all afternoon; he returned home at 5 p.m.
This experience is not unique. There is a disparity in access to care throughout
the Indian health care system. For example:
In fiscal year 1998, there were 74 physicians per 100,000 AI/AN beneficiaries,
compared to 242 per 100,000 in the overall U.S. population;
In fiscal year 1998, there were 232 registered nurses per 100,000 AI/AN bene-
ficiaries, compared to 876.2 per 100,000 in the overall U.S. population;
In fiscal year 1998, there were 289 public health nurses in the IHS. This rep-
resents a ratio of 19.8 per 100,000 AVAN beneficiaries;
In fiscal year 2000, there were 21 IHS psychiatrists;
In fiscal year 2000, there were 63 IHS psychologists;
In fiscal year 2001, there were 19 podiatrists to treat the more than 60,000 AI/
AN diagnosed with diabetes;
In fiscal year 2001, there are 11 vacancies for optometrists. Unless these posi-
tions are filled, 27,500 patients will not receive care;
In fiscal year 1998, the dentist to AI/AN beneficiary ratio was 1:2,793 compared
to 1:1,743 for the overall U.S. population; and,
In fiscal year 1999 there were only 20 registered dietitians per 100,000 AI/AN
beneficiaries.
Another way to view this situation is to compare the IHS to the Veterans Admin-
istration. For example, the Carle T. Hayden Veterans Medical Center and the PIMC
are within a mile of each other in central Phoenix. The total number of outpatient
visits at the VA facility was 8,339, compared to 14,400 at the PIMC, a difference
of 6,060. The VA employs 9.5 psychologists, while the PIMC employs 4 psycholo-
gists. The total number of behavioral staff at the VA was 75.5, as compared to the
17 behavioral staff at the PIMC.
While the disparity to access to care is most pronounced in the IHS, it will not
be long before the rest of the country will see similar problems. Various health pro-
fessions are already experiencing or expect to experience shortages in the near fu-
ture. For example:
According to the American Hospital Associations June 2001 TrendWatch,
126,000 nurses are currently needed to fill vacancies at our nations hospitals.
Today, fully 75 percent of all hospital personnel vacancies are for nurses;
According to a study by Dr. Peter Buerhaus and colleagues published in the
Journal of the American Medical Association [June 14, 2000], the United States
will experience a 20-percent shortage in the number of nurses needed in the
United States health care system by the year 2020. This translates into a short-
age of more than 400,000 RNS nationwide;
In the next 20 years, 85,000 dentists will retire and only 81,000 will replace
them;
 51
The June 2001 TrendWatch also reports that hospitals have a 21-percent va-
cancy rate for pharmacists; and
Podiatry has experienced a nearly 50 percent reduction in its applicant pool
since the 1990s. In addition, the number of graduates is also dropping. This is
occurring when most States have only 1 to 4 podiatrists per every 100,000 citi-
zens. Federal estimates recommend 6.2 podiatrists per 100,000.
The Friends believes that by improving access to treatment and preventive serv-
ices the IRS will be able to make significant strides in reducing health disparities
and morbidity and mortality rates in the AI/AN population. Evidence of this was
demonstrated by the placement of a full time podiatrist with the Winnebago and
Omaha tribes. During his 4-year tenure, the average annual 16 leg amputations fell
to zero. Not only did this improve the daily living and quality of life for tribal mem-
bers and their families but there was a considerable cost savings also. On the aver-
age, medical and surgical costs associated with leg amputations can average $40,000
a piece. This one podiatrist saved the tribes over $2 million in surgical expenses
during his tenure.
But the IHS needs to move quickly to better recruit and retain health care provid-
ers now. If the Administration waits too long then in the near future when competi-
tion for health care providers throughout the country becomes more intense, the IRS
will not be able to compete for these workers. In order for that to happen, Congress
needs to make it easier for the IHS to recruit health care providers.
Suggested Solutions;
1. Loan Repayment
The most successful recruiting tool that the IHS has is loan repayment. A few
years ago, following recruitment visits to dental schools, the IHS dental branch re-
ceived 100 calls from interested graduating seniors. However, almost every caller
asked about the availability of loan repayment. When they learned that it was mini-
mal, actual applications fell to just over 30. Loan repayment is an excellent recruit-
ing tool. Of the 19 podiatrists serving in the IHS, 13 are receiving loan repayment.
Most health professionals have incurred heavy debt loads during their education.
The average debt load of the 272 people entering the IHS last year was $64,000.
But that figure understates several individual professions:
The average student debt for physicians is $95,000;
The average student debt for optometrists is over $100,000;
The average student debt for dentists is $100,000 [this does not include under-
graduate debts]; and
The average student debt for podiatrists is $110,000.
As part of the Friends fiscal year 2002 appropriations request, we requested that
the IHS loan repayment budget be raised to $34 million. This is an increase of $17
million and would allow the IHS to double its workforce. The IHS could further ex-
tend this funding if Congress were to make these loans tax-free. Under the current
system, Congress not only pays health care providers an annual sum of $20,000 but
also pays an additional 20 percent of that amount for taxes. Therefore, $3.4 million
goes to the Internal Revenue Service. If the loans were tax free, this would allow
the IHS to hire 170 more providers. Just doubling the number of IHS dentists get-
ting loan repayment would mean that 53,000 more dental visits could be scheduled
each year. The Friends recommends that the committee include a provision in S.
212 to make the loans tax-free.
2. Loan Deferment
Under the Higher Education Act, volunteers or members of various health and
Federal programs do not have to repay the principal of, or the interest on, any stu-
dent loan under the Act for 3 years. This includes members of the
Armed Forces,
Peace Corps,
Domestic Volunteer Service,
Full time nurse or medical technicians providing health services, or
Full time employees of a public or private nonprofit child or family service agen-
cy who is providing, or supervising services to high-risk children from low-in-
come communities.
Health care personnel working in the IHS or for tribes are noticeably absent from
this list. Consequently, recent graduates must begin immediate repayment of debt
upon graduation, when their net incomes are at their lowest. For some, that month-
ly payment can be over $1,000. Faced with this burden, many health care profes-
sionals cannot afford to join the IHS, whether as Commissioned Corps, Tribal hires
or urban hires. For those who do take the risk of joining while waiting to be accept-
ed for loan repayment, many soon discover that they cannot make ends meet be-
 52
cause of their enormous debt load and leave the IHS to accept more lucrative oppor-
tunities. Therefore, the Friends recommends that the Committee correct this omis-
sion in S. 212 in order to improve the recruitment and retention of IHS health pro-
fessionals.
The need for a robust loan repayment and deferment program is especially critical
when one considers that the IHS pay scale lags far behind the private sector. For
example, in 1998, the average net income among general practice dentists that grad-
uated less than 10 years ago was $141,690, while the newly graduated dentist in
the Commissioned Corps earned slightly more than $50,000. Similarly, the average
annual income for IHS pediatricians is nearly $40,000 less than for pediatricians
in the private practice. This occurs despite the fact that one-third of the AI/AN pop-
ulation is under the age of 15.
3. Housing for Health Care Providers
Another important aspect of recruiting health care personnel is adequate housing.
At some sites, health care providers have reported it is discouraging to have to live
in housing that is worse than college dorms. The American Dental Association re-
ported to Congress, following a 1997-site visit, that a dentist was leaving a remote
site because of the unlivable conditions of her mobile home. No suitable housing
could be found to retain her services. In some areas, health care providers are forced
to live miles away, often in other States, in order to find decent housing for them-
selves and their families. The Friends believes that the IHS needs to assess its staff
quarters and develop a consistent approach to replacing or building new staff quar-
ters. Therefore, the Friends recommends that committee include a study of staff
quarters and a proposal for addressing the situation in S. 212.
4. Exit Interviews:
As the IHS approaches the next decade and must compete for health personnel
with the rest of the country, the Friends believes that it would be very helpful to
require exit interviews of departing employees. Determining whether staff are leav-
ing because of non-competitive salaries, high debt burden, inadequate housing,
spousal needs or a lack of an esprit de corps would be essential to quickly making
corrections to prevent others from leaving. The Friends has heard anecdotal stories
that because of the Government Performance and Results Act [GPRA] that midlevel
support personnel have been lost and paperwork burdens have increased. These
changes directly impact on patient care. They decrease the number of patients that
can be treated and reduce prevention education programs which help to keep down
the level of disease. Health care providers feel overburdened which leads to bum out
and retention problems. For example, the financial resources in the IHS are at 40
percent of that need to provide mental health services. Most Service Units and Trib-
al programs are operated with one or two providers, who provide primarily crisis-
related services with little backup due to the isolated, rural nature of their practice.
Not surprisingly, professional burnout leads to rapid turnover, adversely affecting
the availability of a single backup psychiatrist, let alone the essentials of an ade-
quate, cost-effective mental health program. Maintaining strong patient-provider re-
lationships is essential to good care, but if the provider doesnt stay long enough
to form such a bond, it undermines the care and prognosis of the patient.
Increasing the Use of Students and Volunteers
The IHS employs approximately 500 pharmacists. Many of them joined the IHS
after completing a residency at IHS sites. The pharmacists have 11 IHS sites where
students can do their residencies. Interestingly, new pharmacist hires have a better
retention rate than other health care professionals during the first 5 years of work-
ing for the IHS. While the Friends cannot state for sure that this is due to the stu-
dents early exposure to the IHS we recognize that such a program offers great op-
portunities. We would like to see the IHS work with other professional organizations
and education groups to create similar programs. We believe that this would help
to ease the provider shortage on a short-term basis when the students are at the
sites and possibly in the long run for recruitment efforts.
In addition, the Friends would like to see the IHS explore ways to recruit active
and retiring health care professionals interested in providing care on a part-time or
temporary basis. For example, the American Academy of Pediatrics has received
more than 300 requests from active physicians for information about its Locum
Tenens program, a national initiative that identifies short-term pediatric opportuni-
ties at IHS sites. Additional, we believe that many other providers are not ready
to completely retire and would be willing to volunteer a week, a few days a month
or even 6 months of their services. Their experience and expertise, particularly spe-
cialists like OB/GYNs, psychiatrists, oral surgeons, and orthopedic surgeons are in
high demand. However, in order to make use of these professionals the IHS needs
to create a program where such volunteers can be recruited, enter easily without
a lot of paperwork, provide adequate housing and assure the volunteers that liabil-
 53
ity would not be problem. The Friends recommends that the committee include in
S. 212 a pilot project to create such a program in consultation with professional or-
ganizations. Individual members of the Friends would be pleased to work with the
IHS on such a project.
Thank you Mr. Chairman and members of the committee for offering the Friends
of Indian Health the opportunity to testify today on the Indian Health Care Im-
provement Act. We hope we have provided the committee with thoughtful sugges-
tions and we will try to answer any questions you might have.

FRIENDS OF INDIAN HEALTH

AIDS Action
American Academy of Child & Adolescent Psychiatry
American Academy of Family Physicians
American Academy of Ophthalmology
American Academy of Pediatrics
American Academy of Pediatric Dentistry
American Academy of Physicians Assistants
American Association of Colleges of Nursing
American Association of Colleges of Osteopathic Medicine
American Association of Colleges of Pharmacy
American Association of Colleges of Podiatric Medicine
American Association of Dental Schools
American Cancer Society
American College of Obstetricians and Gynecologists
American College of Osteopathic Family Physicians
American College of Physicians
American Dental Association
American Diabetes Association
American Dietetic Association
American Geriatrics Society
American Hospital Association
American Medical Association
American Nurses Association
American Occupational Therapy Association
American Optometric Association
American Osteopathic Association
American Pharmaceutical Association
American Podiatric Medical Association
American Psychiatric Association
American Psychological Association
American Public Health Association
Arizona Academy of Family Physicians
Association of Schools of Public Health
Friends Committee on National Legislation
National Kidney Foundation
National Rural Health Association
National Native American AIDS Prevention Center
George Blue Spruce, D.D.S.
Ward Robinson, M.D.
William Treviranus, D.O.
James Zuckerman, M.D., Harvard Medical School

PREPARED STATEMENT OF CAROLE MEYERS, EXECUTIVE DIRECTOR, MISSOULA INDIAN

CENTER, MISSOULA, MT
Honorable Chairman and committee members, my name is Carole Meyers, execu-
tive director for the Missoula Indian Center, Missoula, MT. I am an enrolled mem-
ber of the Blackfeet Tribe and also a descendent of the Oneida and Seneca Tribes.
I would like at this time and thank you for this opportunity to testify before your
committee on the issues of urban health problems in Missoula, MT.
The Missoula Indian Center is a Non-Profit 301 c. (3) organization and has been
in existence in Missoula, MT since April 1970. This organization has assisted the
Native American community in Missoula for thirty-one (31) years as a health refer-
ral agency. The population of Native Americans in the Missoula Community is ap-
proximately 3,100 people with, 65 tribal representations from across the Nation.
Missoula, MT has a population of 74,000, home of the University of Montana, which
 54
many of the Native American people who move to Missoula attend the University
system. Montana has seven (7) reservations and there are eleven (11) different
tribes that live in each area. When Native Americans leave their home reservation
and move to an urban area, such as Missoula, they face many obstacles. One of the
most noticeable is their health coverage. Once they live in an urban area for 180
days, they loss all of their Indian Health Service coverage.
I want to go on record that I fully support the passage of Indian Health Care Im-
provement Act Reauthorization of 2001 S. 212. This reauthorization of this bill
would allow Native American people to receive the necessary health coverage to
enjoy a long and healthy life.
The definition of Urban Indian means any individual who resides in an urban
center and who-(A) regardless of whether such individual lives on or near a reserva-
tion, is a member of a tribe, band or other organized group of Indians, including
those tribes, bands, or groups terminated since 1940 and those tribes, bands or
groups that are recognized by the States in which they reside, or who is a descend-
ant, in the first or second degree, of any such member.
This definition needs to part of the Indian Health Care Improvement Act. In order
for the Urban Indians to receive adequate funding; we need to be recognized as our
own unique group of Indian people. Living away from the reservation does create
different situations.
Below is a listing of the program the Missoula Indian Center provides:
Indian Health Service
Immunization Health Promotion/Disease
Prevention AIDS
Alcohol
Mental Health
Diabetes
Adolescence Substance Abuse Program
Health
Chemical Dependency Program
Missoula County
Alcohol
State of Montana
Alcohol
Tobacco
The Missoula Indian Center is governed body by a 7-member Board of Directors,
of which, 51 percent, must be Native American. The Missoula Indian Center is orga-
nized under two major programs; the Health Programs and the Chemical Depend-
ency Programs. There are 11 full-time staff and one part-time Mental Health Coun-
selor.
The health issues that surround the Native American population range from dia-
betes to the common cold.
With our agency as a health referral organization, many of our clients may see
as many as three (3) to five (5) different health providers in a course of 1 year. With
this inconsistency of health providers, there is not a medical history that follows the
clients. This creates more confusion and lack of medical knowledge of the clients
history. Many times, because of lack of funding, clients will be referred to at the
point of emergency medical attention. There is very little prevention health care,
such as a yearly physical or dental check-ups.
The Missoula Indian Centers Health program provides quarterly clinics that
cover basic health issues. Which, in itself is an excellent program activity. But a
significant problem the Health program faces is, if a client has a medical problem
we do not have the resources to provide the medical follow up that is necessary. For
example, at our quarterly, clients are provided with a blood screening, this is a very
through medical screening. If a clients medical report comes back as an issue, they
are basically on his or her own to seek medical assistance. It is a safe estimate that
80 percent to 90 percent of our clients do not have medical insurance so they look
to us for their medical needs but we do not have the funding resources to help them
in their crisis. The only thing we can advise them if to go back to their home res-
ervation to seek medical help but some require a 6-month waiting period for resi-
dency purposes.
The Missoula Indian Center had 8,865 encounters this past year. These encoun-
ters are community members who access the center for medical issues, drug and al-
cohol counseling to utilizing the telephone. We are looked upon as a One-Stop
agency for many needs other than medical. Other prevalent issues besides the
health are: No. 1, housing; No. 2, employment; No. 3, school (K12 and Higher Edu-
 55
cation); No. 4, law enforcement and; No. 5, food. These are a few that we see on
a daily base if not weekly.
The center staff networks with other agencies within the Missoula community,
such as Office of Public Assistance, Casey Family Foundation, Youth Court, Adult
Parole and Probation, Pre-Release Center, Missoula County School District, Mis-
soula Food Bank, Public Health Clinic, Now Care, Missoula Housing Authority,
Human Resources, City Police Department and Missoula County Sheriffs Depart-
ment, just to mention a few. Networking within the community is important be-
cause many of our Native American clients utilize those agencies and if there are
issues that clients face, we can advocate for them. The Missoula Indian Center of-
fers In-Service training for those agencies that want a better understanding the
type of services we provide.
Presently, we contract with other health agencies, such as Partnership Health
Clinic at a reduced cost for a doctors visit. This enables Health funds to cover more
clients over the course of a year. But this does not address a clients need for medi-
cal followup or maintenance.
When a client needs to have a prescription filled, we are able to transport them
to St. Ignatius on certain days, located on the Flathead Indian Reservation, which
is a 90-mile round trip. Because of the Salish and Kootenia Tribal policies, clients
have to physically present themselves to pick up their medication. This creates some
hardship on our clients due to the fact that they may not have transportation to
drive to St. Ignatius or money to purchase gas for their car. When the health staff
transports, this takes them away from their regular workday.
The other service clients can utilize is the dental clinic. But in order for a client
to be seen, it has to be an emergency and they have to be at the dental office by
8 a.m. in order to be seen by a dentist. This means, the client has to leave Missoula
by 7 a.m. in order to have dental care. And once again, by the time they need emer-
gency dental, it is a tooth ache or some type of infection and it is in a crisis setting.
Plus, this trip can and is often dangerous drive to St. Ignatius because of the haz-
ardous weather conditions Montana has during the winter months.
As you can read in my testimony, there are many factors that play in to affect
when it comes to the health issues of Native Americans living in an urban area.
Native Americans leave their home reservation for many reasons. The most preva-
lent is education. Trying to achieve a higher education degree is of the utmost im-
portance from many. This enables individuals to have a better life style, achieve a
goal not too many Native Americans have been able to accomplish in the past. But
in order for them to achieve this goal, they have to move to an urban area to attend
a 4-year higher education institution. At times, it can be very difficult in the sense
they experience culture shock when they move to an urban location. The transition
period for adjustment can be up to 1 year to feel comfortable and cope with many
of the difficulties they encounter. Within the capacity of my job, I have seen many
Native Americans try to better themselves and their families but at times when
they are faced with medical problems or other issues and no where to turn, the only
alternative would be for them to move back home and at times, the cycle poverty
or frustration continues.
The Chemical Dependency programs the center offers are Intensive Outpatient
and Standard Outpatient with some group/individual counseling sessions. Since
these programs are Montana State Certified that enables them to apply for other
funding through State and County programs. Not only the Native American clients
utilize these programs, the non-Native Americans attend these sessions. The type
of programs the center offers has a Native American/spirituality theme and many
of the clients who participate have commented that a wholelistic approach to their
addictive issues has benefited them with their recovery. The Missoula Indian Center
is the only program in the Missoula area that offers this type of services. Other pro-
grams in the Missoula area have recognized the spirituality of these Chemical De-
pendency counseling sessions and have commented the uniqueness of them.
The health programs assist with the Chemical Dependency clients. They offer HIV
testing and counseling, Hepatitis-C testing, and encourage them to attend the quar-
terly clinics they offer. Many of them not only come in with an addiction problem
but as well noted stems into many health issues.
Diabetes is a prevalent health issue that is on the rise with many of the recovery
alcoholic. One incident that comes to mind is a pre-release client utilizing the Chem-
ical Dependency program complained of having a blister on his foot. The pre-release
staff accompanying him that day thought it was not a big deal but I told her that
a blister on a diabetic could be fatal. She was not aware of the significant problems
that Native American diabetics face everyday with their disease. I offered to have
the health staff come to the Pre-Release Center and provide their staff with an In-
Service on the health issues of diabetic clients.
 56
I want to thank you for your time for listening and reading my testimony; it has
been a privilege and honor to come before you with my thoughts and ideas. Each
and everyday Native Americans are faced with issues and problems of health, em-
ployment, and education. I sincerely hope with my testimony that our issues have
been personalized and survival on day-to-day bases for the Native American peo-
ple is a very real issue.

PREPARED STATEMENT OF MARTIN WAUKAZOO, EXECUTIVE DIRECTOR, URBAN

HEALTH BOARD, INC., NATIVE AMERICAN HEALTH CENTERS SAN FRANCISCO AND
OAKLAND, CA
Although the majority of Native Americans live in urban settings, most Federal
funding for Native health care and community initiatives goes to those who continue
to live on reservations. The basic medical and dental needs of urban Indians are
unmet in addition to other areas including mental health, substance abuse, HIV/
AIDS prevention and treatment, diabetes prevention and treatment, and capital
needs. Urban Indian Health Board, Inc. was established in 1972 to address the
health needs of the urban Indian population of the San Francisco Bay Area. In that
year, Indian Health Services [IHS] funding comprised ninety percent of our operat-
ing budget. Today, IHS grants amount to only 14 percent of our total funding. Our
success in fundraising and in service delivery can be attributed to decades of sac-
rifice and persistence. However, consistent funding is becoming more difficult to
achieve when costs rise faster than the needs of our service population.
Our service area is the five counties of the San Francisco Bay Area including Ala-
meda, Contra Costa, Marin, San Francisco, and San Mateo Counties. Preliminary
Census 2000 figures show nearly 80,000 Native American/Alaska Native and multi-
race/Native individuals reside in these five counties. The Bay Area has one of the
largest concentrations of urban Indians in the country.
Urban Indian Health Board, Inc. is a nonprofit 501(c)(3) community health care
provider operating two licensed clinics, one in San Francisco, since 1972, and one
in Oakland, since 1983. We employ 120 health workers. Our operating budget for
the current year is $7.1 million. The Board of Directors is composed entirely of Na-
tive Americans and serves on a volunteer basis.
Ninety-eight percent of Native American patients served meet the Federal poverty
level guidelines. In 2000, the medical clinic saw over 4,800 patients with over 16,800
visits. Many of our patients are members of tribes from across the United States
with the largest number representing California tribes, Navajo, Lakota, Pomo, Cher-
okee, Apache, Paiute, Blackfeet, Choctaw, and Chippewa.
Our services reflect our expanded definition of health: The health of an individual
depends upon the health of a community. Since our agency is one of the few Native
organizations in the Bay Area, we are in a unique position to directly impact our
communitys health. Thus, we function as far more than a medical clinic. As part
of our mission to contribute to the health and growth of our community, we offer
adult and pediatric services in our two clinic settings; womens health care; prenatal
care; a WIC program; comprehensive dental care; mental health services including
substance abuse counseling; fitness and nutrition counseling; health education and
outreach; and a variety of youth initiatives through our Native American Youth
Services program.
We believe health is whole-body and community-based. Urban Indians feel a sense
of isolation and disconnect from the broader community. As a health service pro-
vider, we step in to try to ameliorate that feeling of isolation among our community
members. Our clients are disproportionately young, poor [nearly every client in 2000
was below the poverty line, with fully 13 percent at 200 percent or more below pov-
erty level], and impacted by physical and mental health issues specific to a people
that has suffered cultural and physical dislocation and decades of poverty. Dispari-
ties have arisen in disease and mortality rates between Native peoples and the gen-
eral population. We believe these disparities are due to the consequences of poverty
and cultural dislocation, with urban environments like our own only exacerbating
the lack of family and traditional support systems.
We face several overlapping challenges: Those specific to urban Native popu-
lations, and those specific to the Bay Area. For instance, the rate of substance abuse
is higher for urban Native Americans than for any other ethnic group, while the
rate of HIV/AIDS among Native Americans is higher in the Bay Area than in any
other Native service area. In the five counties, we estimate that over 75 percent of
Native American families suffer from substance abuse, domestic violence, and men-
tal illnesses. Additionally, we believe that over 50 percent of urban Native American
children are emotionally disturbed or at high risk for mental illness, substance
 57
abuse, and delinquency. The suicide rate for Native American teenagers is higher
than for any other group.
Another challenge we face is a disproportionate rate of diabetes. In a local study
we conducted last year, we found that two-thirds of the adults and youth in the
study group fell into the nutritionally poor to very poor category. This correlates
with our experience that the most common physical problems facing our patients are
diabetes, heart disease, obesity and chemical dependency. Poor dietary practices and
lack of exercise contribute directly to heart disease and the development of diabetes.
Urban Indian Health Boards operates two licensed clinics but we are treated by
Indian Health Services as one entity for funding, programmatic and evaluative pro-
cedures. Although there are 34 urban Indian clinics in the nation, our clinics are
counted as one site. Funds for urban clinics for some programs are distributed now
via a simple method of division between the 34 urban sites across the country that
serve Native Americans.
We advocate that the formula for distribution be redrawn to coincide with the
number of Native people in the service area and that areas cost of living. This de-
termination would far more accurately reflect the costs of providing care to those
in need. For instance, additional money for diabetes care was recently distributed,
yet our clinics received only a tiny portion of that funding despite the fact that a
full twenty percent of our 18,000 patient visits were due to diabetes.
There is no urban clinic IHS funding available for capital needs. Our agency is
stretched beyond our limits as we struggle to meet the increasing demand for serv-
ices. Presently, we are at full capacity and need immediate capital funds. Existing
facility problems such as poor design, insufficient exam rooms, inadequate informa-
tion systems and technology, and limited access for the handicapped result in the
inefficient provision of services. Capital investments in urban Indian health centers
will increase access to primary and preventive health care.
The cost of providing health has increased significantly over the years. Pharmacy
costs, which accounted for 44 percent of health care costs nationwide last year, is
growing much faster than other components of health care. Providing this benefit
for indigent patients has become an overwhelming financial drain on our clinics.
Our clinics pharmacy costs increased by 34 percent from fiscal years 199899 to
19992000. Pharmacy costs have skyrocketed so significantly that they directly re-
duce our ability to provide primary care services, as we must devote more of the
IHS funding to cover the cost of prescription drugs.
Health insurance premiums for our employees have also increased dramatically
over the past 3 years. The premium rate for our clinic has increased by 28 percent
in the past 3 years. The increase in health insurance premiums directly reduces the
clinics ability to provide primary care services. As we spend more money to provide
health insurance for our employees, there are fewer funds available to provide care.
The California energy crisis is also having a major impact on our clinics. Our clin-
ics utility costs have increased by approximately 40 percent this fiscal year. Finally,
workforce issues have also had a tremendous impact on our clinics. Our clinics abil-
ity to provide quality health care is limited by the number of health care profes-
sionals that we are able to hire and retain. Often, salaries are not competitive
enough to attract various health care professionals. In addition, vacancies directly
limit the resources that we have to serve our community.
A disproportionate number of Native Americans are ineligible for any subsidized
insurance programs. Our clinic has struggled to respond to the ever-increasing de-
mand for our services, particularly by uninsured patients who have no other system
of health care to utilize. Furthermore, as we enroll more children into health insur-
ance programs, we are seeing changes in the patient mix that reflect an older popu-
lation facing more chronic diseases, with the need for acute care and a greater num-
ber of pharmaceuticals. We are now seeing a greater number of patients with chron-
ic conditions requiring more than one visit and a greater amount of health care
services resulting in increased costs. Because the number of uninsured patients
seeking care at our health centers continues to increase, urban Indian health clinics
need additional funding to cover the ongoing health costs of serving more indigent
patients and patients that have more expensive health care needs.
Ninety-eight percent of our clinic patients are low-income and approximately 60
percent are uninsured. In the past 3 years, we have seen a 10-percent increase in
older uninsured patients. This older population faces a greater amount of chronic
conditions, requiring more acute care, a greater number of pharmaceuticals and
more than one visit. Our data also shows a 30-percent increase in patient visits per
year in the last 3 years. This data likely reflects an increase in clinic patients that
are needlessly suffering from chronic conditions/diseases.
In response, our clinics for the past 2 years have been working on a diabetes man-
agement initiative. While physicians play a key role in diabetes management, other
 58
health care professionals including health educators, community health workers,
nurses, case managers, and nutritionists are crucial to assisting patients in their
disease management by helping individuals learn self-management skills and assist-
ing patients to make behavioral changes in their lifestyle.
In conclusion, our community clinic is a strong and vibrant organization commit-
ted to providing the highest quality of care for our community. As an urban Indian
clinic we must be creative and resourceful to weave available funding opportunities
to address the need of our community. We have developed linkages with the system
of health care in the broader community in the San Francisco Bay Area while at
the same time build alliances with other IHS funded urban programs. For example,
we have a working partnership with the Friendship House of American Indians of
San Francisco who is developing an 80-bed residential treatment facility, the first
major development project in the Indian community of the Bay Area. We are also
working with Friendship House to build a 75,000 square foot Youth Development
Center in Oakland, a project which is in pre-development with anticipated site con-
trol within the next 30 days.
These projects in our community continue to underscore the need for greater in-
vestment in our community. Many times we fall through the cracks and remain un-
recognized within the broader discussions of Indian issues. Although I.H.S. funding
only composes 14 percent of our total operating budget, for every one dollar invested
by IHS we are able to leverage another $6 from other sources.
We have several recommendations which address the level of need in our commu-
nity and will ultimately increase the level of care for our patients. A funding aug-
mentation is required to provide immediate pharmacy relief to allow the our clinics
to maintain their capacity for primary care visits. A special augmentation is also
required that would provide our clinics with relief from health insurance premium
increases. With soaring energy costs already making a tremendous impact upon our
operating costs, we would recommend and allocation to offset increased energy costs
and provide our clinics with additional funds to address the shortage of health care
professionals in our clinics. The demographics of our patient population is ever-
changing along with the cost of care. We recommend an adjustment in the funding
formula that would take into consideration the higher health care costs to clinics
given the changing patient mix. With an increasingly older patient population, we
require Increased funding to cover costs for patients participating in chronic disease
management initiatives. Although we strive to provide a high level of care, capital
needs in our facilities is at an all-time high, we strongly recommend allocations of
funding to address greatly needed capital and facility improvement needs. Finally,
we recommend funding for regional and culturally competent approaches to diabetes
prevention and treatment, substance abuse prevention and care, youth violence pre-
vention and HIV/AIDS prevention and treatment.
We would like to thank the committee for allowing us this opportunity to share
with you our concerns, our successes and our recommendations. Our ability to pro-
vide quality care for our unique community is directly affected by your work and
your commitment. We are fortunate for the opportunity. Thank you.

PREPARED STATEMENT OF KAY CULBERTSON, EXECUTIVE DIRECTOR, DENVER INDIAN

HEALTH AND FAMILY SERVICES
Good morning Chairman Inouye, Vice Chairman Campbell and other distin-
guished committee members. My name is Kay Culbertson, I am an enrolled member
of the Fort Peck Assiniboine/Sioux Tribes located in Poplar, MT. I serve on the
board of directors for the National Council of Urban Indian Health and I am the
Executive Director for Denver Indian Health and Family Services [DIHFS] located
in Denver, CO. On behalf of the Denver Indian Community, I would like to thank
you for the opportunity to provide testimony regarding health issues of Indians who
reside off reservation and the Urban Indian Programs that serve them. There are
currently 34 urban Indian health programs located throughout the United States,
with each program offering a variety of medical service through many creative and
innovative delivery types. Today, my focus will be on Denver Indian Health and
Family Services.
In the past, Denver attracted Indian people for a variety of reasons. Denver was
one of the original sites for relocation of Indian people from their home reservations.
A segment of Denvers Indian population is a result of Indian men and women who
settled here after serving in the armed forces. Another segment came to Denver be-
cause there was a Bureau of Indian Affairs office located in the area. Many Indian
people moved from the reservation to the Denver area with the hope of attaining
the American Dream. And today, Denver continues to be a hub for Indian people.
 59
Denvers Indian population is estimated at 25,000 and is comprised of people who
have lived in Denver for over 30 years producing second and are third generation
Denver natives as well as those who are transient and move to and from the res-
ervation on a regular basis. The universal reason for moving continues to be Hope
for a better future.
Although Denver is centrally located within Indian country and many national
Indian organizations are headquartered in Denver, it is isolated from tribal health
and Indian Health Service services, the closest Indian health facility in Colorado is
located on the Southern Ute Reservation, an 8-hour, drive. The nearest Indian
Health Service Hospitals are in Rapid City, SD and Albuquerque, NM. Unlike other
urban health programs we do not have the ability to utilize other Indian health fa-
cilities to meet the gaps in services.
Denver Indian Health and Family Services was created as the result of a needs
assessment conducted by the Denver Native Americans United. Denver Indian
Health and Family Services was incorporated in 1978, as a non-profit Indian organi-
zation and received funding from the Indian Health Service to provide outreach and
referral services to the Indian community. With a staff of two people, the agency
gathered and provided information to Indian people in accessing health care in the
Denver metropolitan area. Eventually, DIHFS began to provide limited health care
through volunteer nurses and doctors and grew into a full scale clinic entering into
an agreement with Denver Health and Human Services. The number of uninsured
and the inability to charge American Indian patients placed a much larger financial
burden on the organization and clinic services were discontinued in 1991. Unfortu-
nately, the health care needs of the community exceeded the funding limits of the
agency. In 1996, DIHFS entered into an agreement with a local community clinic
to provide services at a limited cost; however, the agency could only allow two visits
per year and the patients were responsible for their own laboratory and x ray costs.
This arrangement made it difficult to provide health care to persons with chronic
medical problems such as diabetes. The community voiced the need for additional
health care. Not just any health care but health care that was culturally sensitive
and available through an Indian organization or provider.
At a 1998 strategic planning retreat the DIHFS board of directors planted the
seeds to begin the process of providing medical services to the Indian community
onsite. The board of directors stressed the importance of taking slow steps to provid-
ing health care. The board of directors insisted that the services be provided by
DIHFS, that patients would receive more health education, that the delivery of serv-
ices be provided in a manner that was comfortable to Indian patients, that the fi-
nancial pitfalls of the past be avoided and that we maintain our identity as an In-
dian provider and an Indian clinic. In March 1999, a young Indian physician, Dr.
Lori Kobrine, took on the task of laying the foundation for our clinic. Through her
efforts our clinic met the requirements for state licensure. She worked 20 hours a
week providing limited medical services to the community. Now our clinic continues
to grow. Since May 2000 our clinic has been staffed with a full time nurse practi-
tioner and a volunteer physician who provide medical services on a full time basis
to the community. The medical services include immunizations, acute emergencies,
well child physicals, physicals, womens basic health, diabetes management and
screening and other health services that do not require a specialist or that are not
life threatening. DIHFS also provides mental health and substance abuse counsel-
ing, substance abuse prevention, case management services for victims of crime, en-
ergy assistance, diabetes case management, prescription assistance, emergency den-
tal, and referrals to meet other community health needs.
The cachement area for DIHFS includes Adams, Arapahoe, Boulder, Denver,
Douglas, Jefferson, and Gilpin counties. However, we also serve people who travel
from as far as Pueblo and Aspen. There is also an increase in services during peak
months of March, June, July, and August for persons who are visiting during the
annual March Pow-wow or who are staying with relatives over the summer. DIHFS
is located in southwest Denver near the old Fort Logan facility. Although located
outside of central Denver, DIHFS is conveniently located near the Denver Indian
Center and Denver Indian Family Resource Center, making referrals to other In-
dian organizations and coordination of case services much easier for Indian clients.
The Denver Indian community is fairly young population with the median age of
30.2 as compared to 34.5 for all other races. The majority of DIHFS clientele are
single parent heads of household. The average income reported by DIHFS patients
is $621 per 4 month or $7,452 per year. Seventy-three percent of DIHFS patients
do not have health insurance.
The Medical Clinic provides onsite services through a family nurse practitioner.
Appointments are scheduled for 1 hour at time to allow for intense patient edu-
cation regarding their presenting problem. The most common diseases treated in the
 60
clinic are diabetes, hypertension and dental pain. Wellness screening services in-
clude womens health, family planning, mens health, well child checks and edu-
cation.
The Community Health Program is the most often utilized program is the agency.
DIHFS assists with prescriptions purchases, energy bills, adult emergency dental
through a contract dentist, referrals for denture purchases, transportation, tribal en-
rollment for patients, optical exams and glasses and many other health related
problems. Education regarding the importance of health insurance [private or pub-
lic] is stressed in the Community Health Program. We currently have a Denver
Health Authority navigator stationed at our office to assist Indian people with ac-
cess the Denver Health system and walk clients through the enrollment procedure
for the State Child Health Plan and Medicaid.
Our Diabetes Program is staffed by a Certified Diabetes Educator and has focused
on bringing traditional foods back into our diets. The focus has been on the Plains
Indian diet with additional research on Southwest Indian traditional diet. Diabetic
patients are provided with free glucometers, and strips to encourage regular check-
ing of glucose levels. The project also assists diabetic patients with special eye
exams, podiatry checks, shoe inserts, shoes, glasses and medications.
Behavioral Health services include mental health and substance abuse counseling
and youth substance abuse prevention support in area schools. The program assists
with antabuse physicals and medication, psychological evaluations and court sup-
port. The outpatient and womens counseling program are the only American Indian
programs in the Denver area that are licensed through the Colorado Department
of Health, Alcohol and Drug Abuse Division.
Victims of Crime Act funds a small case management project for Indian victims
of crime. The Bureau of Justice Statistics released a report in February 1999 detail-
ing the rates of victimization for Indian people. The study found that American Indi-
ans were victims of violence at twice the rate of the U.S. population, that rates of
violence are higher than any other group in every age group, and that alcohol was
more often involved in crimes against American Indian persons at double the rate
of any other race. These are sobering statistics.
As you can see DIHFS has accomplished a great deal with the limited amount
of funding; that is received and the limitations of our community. We have learned
to build relationships with other programs and meet some but not all of the gaps
in service delivery to American Indian people living in the Denver area.
In providing services we have encountered barriers that tribes may not face. If
we accept Medicaid, become a National Health Service Corp provider, federally
Qualified Health Center or a 330 Community Health Center our services must be
open to all people. This places a strain on our identity as an Indian clinic.
Seventy-three percent of the patients seen in our clinic do not have insurance be-
cause they are underemployed, have recently moved to the area, the employer does
not provide health benefits or they do not qualify for any other health benefits.
Often Indian people who come to an urban area have a misconception that urban
Indian health programs are virtually the same as the Indian Health Service or trib-
al health programs on the reservation and may not elect to sign up for health care
benefits. Indian people assume that IHS is everywhere. DIHFS does not currently
have an affiliation with a health maintenance organization [HMO] because we have
neither 24 hour coverage nor hospital admission privileges. These issues also do not
allow us to generate third party billing from Medicaid because the State of Colorado
contracts with HMOs to provide services to the Medicaid beneficiaries. The patients
who have health insurance do not utilize their providers due to the expense of co-
pay amounts or deductibles, they enjoy receiving services at the Indian clinic or wait
times for visits are not as long.
Indian Health Service is severely under funded as a whole, but urban Indian pro-
grams receive the least amount of funding. If urban programs were f1mded at the
same amount and provided the core services of a tribal or IHS facilities, American
Indians living off reservation would have access to comprehensive health care.
Dental services are limited. DIHFS is limited to 10 emergency dental appoint-
ments a month. The dental waiting list is months long. Affordable dental care is
difficult to find, even for persons with private or public insurance. Very few dentists
accept Medicaid patients. Only one urban program has received funding from the
Indian Health Service for dental services.
Hiring and retaining quality professionals has been difficult. DIHFS has an oper-
ating budget of $430,000. The medical field is highly competitive in the Denver area
and we are not always able to compete with other health facilities for staff. DIHFS
does have the opportunity to provide IHS scholarship recipients with payback oppor-
tunities and although there has been much interest to work in Denver, we are not
 61
able to provide them with a salary and benefit package that is commensurate with
tribal and IHS staff positions of the same level.
Denver Indian Health and Family Services supports S. 212 a bill to amend the
Indian Health Care Improvement Act. We strongly support inclusion of urban In-
dian health programs in title IV, Access to Health Care.
Denver Indian Health and Family Services also supports S. 214 a bill to elevate
the position of Director of Indian Health Service to the Assistant Secretary for In-
dian Health. Through the leadership of Dr. Michael Trujillo and his concept of
Speaking with One Voice there has been an increase in support from both tribal
leaders and Indian Health Service professionals to address the needs of tribal mem-
bers who live off reservation. The elevation of the Director to Assistant Secretary
will benefit both tribes and urban programs in their ability to access other Depart-
ment of Health and Human Service programs as well as to bring to the forefront
the severe disparities in health for Indian people as a whole.
Denver Indian Health and Family Services also supports S. 535 a bill to amend
the Social Security Act to clarify that Indian women with breast or cervical cancer
who are eligible for health services provided under a medical care program of the
Indian Health Services or a tribal organization are included in the eligibility cat-
egory of breast or cervical cancer patients added by the Breast and Cervical Cancer
Prevention and Treatment Act of 2000. We recommend that urban Indian health
programs also be included in the eligibility category. During my testimony to the
Senate Committee on Indian Affairs in March 2000 regarding the Indian Health
Care Improvement Act, I relayed a story of a woman with breast cancer who did
not have insurance and had no way of receiving services. Her only option was to
return to the reservation and hope that Indian Health Service would extend cov-
erage to her. We may be able to avoid these scenarios if urban Indian health pro-
grams are included in S. 535.
Denver Indian Health and Family Services also strongly recommends that the fea-
sibility of additional demonstration projects such as those located in Tulsa and
Oklahoma City be funded. We recommend that one site be funded in an area that
is isolated from other IHS or tribal facilities. It is recommended that the project in-
clude provisions for comprehensive medical, dental, and hospital services.
Once again, thank you for the opportunity to testify on behalf Denver Indian
Health and Family Services. I would like to close my testimony with the following
story:
My son is active with the local Native Lacrosse Program. There are approximately
25 Indian families who regularly participate in this most worthwhile sport. The pro-
gram not only promotes exercise and culture but also serves as an informal social
support system for parents while the youth practice. I was writing my testimony
for today when a young mother named Laura inquired about my work. I told her
that I was working on addressing urban Indian health issues to the Senate Commit-
tee on Indian Affairs. She became very excited and went into great length about the
need for more comprehensive health care for Indian people in Denver. She told me
of the birth of her twin children and how her diabetes had caused complications in
the pregnancy. The young family did not have health insurance because of layoffs
and they were not eligible for other services. She was told by her family to go home
to Oklahoma and have her twins at the Indian hospital but she chose to stay be-
cause they could not afford to travel back home. She gave birth to her children at
an area hospital. The twins were kept in intensive care for an extended amount of
time. After the twins were released from the hospital the family was presented with
a $45,000-hospital bill, a bill that they would never be able to satisfy. The family
had to file for bankruptcy and today continues to suffer from the effects of that ac-
tion. Laura asked me why she was not allowed to have the same medical care as
her brothers and sisters who live on the reservation, why was there not an IHS fa-
cility for people in Denver? She asked that I tell you this story today. I hope that
in the near future I will be able to tell Laura that you heard her questions and pro-
vided the Denver Indian community with additional health care resources.

PREPARED STATEMENT OF WAYNE TAYLOR, JR., CHAIRMAN, HOPI TRIBE

Thank you, Chairman Inouye, Vice Chairman Campbell, and other distinguished
members of the Senate Committee on Indian Affairs for allowing the Hopi Tribe to
provide testimony on S. 212, legislation to reauthorize the Indian Health Care Im-
provement Act. We are grateful for your continued attention to improving health
care services for all Native Americans.
The Hopi Tribe looks to Congress as the ultimate Federal trust authority. Vested
in your authority is the ability to ensure the provision of quality health services for
 62
all Native Americans. We value your counsel and depend in no small measure on
your assistance in establishing an array of health services of critical importance to
all tribes.
I would like to provide the Hopi Tribes comments on four provisions of title II
of S. 212 dealing with medical services covered by the Indian Health Service [IHS].
Each of these four provisions addresses a service area that is critical for the im-
provement of the health status of the Hopi people, and we strongly urge the commit-
tee to enact the strongest possible provisions in these areas during the 107th Con-
gress.
The Hopi Tribe strongly supports requiring the Secretary of Health and Human
Services, through the IHS or Indian tribes or tribal organizations, to provide mam-
mography screening for Indian women at an appropriate frequency under national
standards and consistent with those established for the Medicare program. It is es-
sential to the improvement of the health and survival of Indian women that the IHS
and tribes be able to significantly increase the availability of early screening, diag-
nosis and treatment.
One- and 5-year breast cancer survival rates are significantly lower among South-
western American Indian women compared with non-Hispanic whites, despite the
lower rates of breast cancer observed in the Indian population. One of the major
factors contributing to this poor rate of survival is the later stage at which breast
cancer is diagnosed in the Indian population.
The reduction in breast cancer mortality when screening mammography is avail-
able to American Indian populations is estimated at 27.9 percent. Among popu-
lations whose disease is more advanced when it is first diagnosed, as among South-
western American Indian women, the reduction in mortality with screening mam-
mography increases another estimated 26.4 percent.
The 1993 Healthy Hopi Women Survey of 559 women on the Hopi Reservation
confirmed the lack of knowledge about breast cancer screening. Only 55.7 percent
of these women had knowledge of a mammogram procedure, and less than 20 per-
cent knew when women should begin to have screening exams. Only 61 percent of
the women surveyed reported having annual clinical breast exams as recommended
by the American Cancer Societyless than one-half of the women 40 years and
older had ever had a mammogram and only 26.4 percent had one in the 2 years
preceding the survey. The results were similar for women age 50 and olderless
than 25 percent of those women had both a mammogram and a clinical breast exam
in the 2 years preceding the survey. The survey confirmed that the proportion of
women receiving screening mammography and clinical breast examinations is sig-
nificantly lower than the rate proposed in the Year 2000 goals.
The Hopi Tribe Breast and Cervical Cancer Early Detection Program currently
provides breast screening services to women 40 years and older. The program works
in collaboration with Indian Health Service to provide mammography services to
women who are seen through the program or through Indian Health Service. At this
time, Indian Health Service is unable to cover the cost of services for mammography
services and will provide women with mammography service only when it is nec-
essary. Often times, many women who are covered under Indian Health Service for
mammography services are already at high risk for cancer. The Hopi Tribal Breast
and Cervical Cancer Early Detection Program currently covers the cost of mammog-
raphy service for all women who reside on the Hopi Reservation and who are eligi-
ble through the program. Women who are not eligible through the program are un-
able to receive a mammogram unless they pay for the cost or have private insurance
to cover the cost.
To date, 48 percent of enrolled Hopi women ages 40 and over have been screened
through the Hopi Tribal Breast and Cervical grant program. Although nearly one-
half of the women in this age category have been screened, there is still a need to
screen the other 52 percent of the population. While the Breast and Cervical Early
Detection provides breast and cervical screening to all women, services are limited
due to the lack of a full-time womens health provider as well as the availability
of space for services.
With additional funds available to provide screening services, the Hopi Tribe will
be able to screen all women regardless of their eligibility through the program. The
program will also be able to hire a full-time physician to provide screening services
to women on a daily basis and eliminate the waiting time of 3 months for a womens
health exam. Outreach and awareness in the community is essential, as many Na-
tive American women do not understand the importance of early detection. The
Hopi Tribe needs additional funding to increase our ability to provide preventative
breast and cervical cancer services, thereby decreasing the cancer rate for native
women and improving the chance of survival for women who suffer breast or cer-
vical cancer.
 63
The Hopi Tribe also strongly supports the Native American Breast and Cervical
Cancer Treatment Technical Amendment Act of 2001 introduced by Senator Jeff
Bingaman [DNM], which would correct an oversight made by Congress when it en-
acted the Breast and Cervical Cancer Prevention and Treatment Act of 2000. Sen-
ator Bingamans bill [S. 535] would ensure that Indian women with breast and cer-
vical cancer who are eligible to received health services from the IHS or a tribe or
tribal organization will be included in the optional Medicaid eligibility category of
breast and cervical cancer patients added by the 2000 legislation. Without this legis-
lation, Indian women who are diagnosed with breast or cervical cancer through the
CDC program may still find themselves ineligible for coverage of any treatment
services. We strongly urge the committee to support the prompt enactment of this
legislation.
The Hopi Tribe is also strongly supportive of the provisions of S. 212 to require
the Secretary, acting through the IHS or tribes or tribal organizations, to provide
funds for appropriate patient travel costs, including transportation by ambulance,
specialized vehicle or private vehicle, or by air transportation or such other means
as may be available when ground transportation is infeasible.
We have presented testimony to the committee in the past regarding the difficulty
of providing necessary emergency medical transportation services on geographically
remote reservations such as ours. Insufficient funding for adequate staffing and out-
dated equipment has left our existing emergency medical service [EMS] team con-
stantly struggling to provide services. While they do a wonderful job, our EMS per-
sonnel are stressed for time and lack the equipment necessary to perform certain
lifesaving functions. Our program lacks the resources to staff the program according
to industry standards for the time and distances involved in rural transport.
The closing of reservation hospitals in Indian country and replacing them with
ambulatory care centers and consolidating medical services adds to the burden on
emergency medical services teams and magnifies the importance of providing nec-
essary emergency and non-emergency transport. Patients must now travel longer
distances for necessary inpatient care, requiring highly trained personnel as escorts
and more advanced equipment. Thus, the change health care system itself is in-
creasing the critical role of emergency transportation and advanced life support care
yet the system has failed to provide the financial resources necessary to meet the
need, resulting in a growing gap in the continuum of health care.
We applaud the committees effort to require the Secretary to provide funds for
patient travel costs. However, we remain concerned that our tribe and others will
have difficulty purchasing the high-cost emergency vehicles and equipment needed
to provide these services. Further, given the historical under-funding of IHS con-
tract health services, we are very concerned that simply requiring the Secretary to
pay for these added costs from already inadequate funds would ultimately fail to
address the problem. We urge the committee to address these concerns as it ad-
dresses the legislation.
We are very pleased that the committee bill recognizes the need to address health
care related services such as long-term care, home- and community-based services
including homemaker/home health aide services, and assisted living services. The
Hopi Tribe, like many others, faces serious challenges in providing necessary health
care for our aging population.
Respect and care for our elders is one of the fundamental elements of Hopi culture
and heritage. As a result, the traditional Hopi concept of family care-giving includes
a cohesive community that emphasizes the desire to keep all members at home
where elders are able to remain active members of the community and participate
in the care of close and extended family members. Since 1978, IHS and Bureau of
Indian Affairs [BIA] statistics indicate that Hopi has maintained the lowest nursing
home placements of all the 19 Arizona Tribes. In this context, it is critical for the
tribe to establish and maintain services that are locally available and accessible to
our elders.
Currently, about 25 to 30 Hopi members reside in respite care facilities located
in Phoenix, Flagstaff, and Payton. It is difficult for family members to travel these
significant distances to visit their elders, and the elders themselves feel cutoff from
their family and community. To remedy this situation, the tribe is seeking funding
support from the State of Arizona to establish Senior Centers in 3 of the 12 Hopi
reservation villages. We have also initiated planning for an on-reservation long-term
and respite care facility. However, there remains a significant need for planning, de-
sign, engineering and construction funding.
The geographical remoteness of our reservation and language barriers have also
made it difficult to access many State services. Service providers must currently
travel 4 hours from their Phoenix office to provide care for Hopi seniors, and even
then they are available for a limited time. All of our elderly are Hopi-speaking with
 64
limited proficiency in English, and they are often discouraged from applying for
state or Federal services because of the communications barrier that exists between
them and their service providers. We are investigating the possibility of establishing
a local, on reservation office in partnership the State agencies and recruiting and
training Hopi-speaking providers to reach a broader client population.
Since 1978 the Hopi Tribe has contracted with the IHS to participate in the Com-
munity Health Representative [CHR] program. There are currently more than 325
Hopi seniors in all 12 reservation villages receiving services ranging from patient
care and monitoring to case management, education and counseling, and disease
prevention. It is crucial that Congress continue to support and increase funding for
this important support program.
In conclusion, thank you again for allowing the Hopi Tribe to present this testi-
mony. We look forward to working with you during the course of your deliberations
on legislation reauthorizing and enhancing the programs provided through Indian
Health Care Improvement Act. I would be pleased to respond fully to any request
for additional information.
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